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THERAPEUTICS 



OF 



Infancy and Childhood 






by 



A. JACOBI, M.D., LL.D. 



THIRD EDITION 




PHILADELPHIA fcf LONDON 
J. B. LIPPINCOTT COMPANY 

1903 



Chx 



the Library of 
congress, 

Two Copi6s Received 

JAN 21 1903 

Copyright Entry 

CLASS CC XXc. No 

COPY B. 



Copyright, 1895, by J. B. Lippincott Company 



Copyright, 1898, by J. B. Lippincott Company 



Copyright, 1903, by J. B. Lippincott Company 



PRINTED BY J. B. LIPPINCOTT COMPANY, PHILADELPHIA, U.S.A. 



THIS BOOK, IN ITS THIRD EDITION, IS 

AGAIN INSCRIBED TO MY FRIEND AND 

LATE CHIEF OF CLINIC 

DR. FRANCIS HUBER 

IN DUE APPRECIATION OF HIS VALUABLE 
AND UNREMITTING SERVICES RENDERED 
THESE TWENTY-FIVE YEARS (UNTIL THE 
LAST HOUR OF OUR COMMON LABORS) 
TO ME, TO THE COLLEGE OF PHYSICIANS 
AND SURGEONS OF NEW YORK, TO OUR 
STUDENTS, AND TO NUMBERLESS CLINICAL 
PATIENTS 



"Die Frucht der Heilung w'dchst am 
Baume der Erkenntniss. Ohne Diagnostik 
keine vernunftige Therapie. Erst unter- 
sucken, dann urtheilen, dann helfen." 

C. Gerhardt. 



PREFACE TO THE THIRD EDITION 

The past four years have not added very much to pedology as a 
special science and art, notwithstanding greatly increased literature 
and the contributions of many men active and well known in general 
medicine and pediatrics. The much-discussed subject of infant feed- 
ing has enjoyed its universal interest, as formerly; no unanimity of 
opinions, however, will ever be reached so long as infants insist upon 
being individualities. The author finds no reason to change to any 
great extent his convictions as laid down in previous editions on many 
questions connected with that subject; after all, the soundness of a 
man's teaching is best demonstrated by the soundness of infant diges- 
tion and the number of living and healthy children. 

In this revision I have made many additions to my book, but no 
actual changes in its general character. The profession seems to have 
approved of my attempt at founding therapeutics on etiology. Their 
connection I have tried to make still closer, and the reader will find 
that in a concise manner much that belongs to pathological anatomy, 
etiology, and diagnosis is utilized in the interest of treatment. In this 
way the book, I think, is a comprehensive treatise on " theory and 
practice," the former being the foundation of the latter. 

To those who offered available criticisms of former editions, and 
principally to those who by their writings during these few years 
added to my knowledge and suggested new thoughts, I herewith beg 
to express my best thanks. These are mainly due to the fifty-three 
gentlemen who contributed to the Festschrift published in my honor 
more than two years ago. Indeed, I know of no collection of fifty- 
three monographs on scientific and practical subjects, almost all 
directly .connected with pediatrics, of equal value. It has been, as 
this book will show, a fruitful source of information to me, besides 
being the greatest honor that ever was conferred on me or on any other 
man. To all its contributors, both in this and in foreign lands, mainly 
to those whom I have not thanked in person, I take this opportunity 
of again expressing my heartfelt gratitude. 

A. Jacobi. 
19 East Forty- Seventh Street, New York, 
January, 1503. 



PREFACE TO THE FIRST EDITION 

Much of what is contained in this work may be claimed as com- 
mon property. Much of it I have taught before. Indeed, very few 
books can ever be written that will be entirely new. Pediatrics is 
not new to-day; nor was it so when, in i860, I established the first 
systematic course, in our country, of clinical instruction in the dis- 
eases of children. Having since that time appeared before the medi- 
cal public with essays and monographs only, I was repeatedly re- 
minded by friends of my obligation to submit to the profession which 
has afforded me so many facilities and advantages a compact picture 
of the therapeutics of infancy and childhood as I have it in my mind. 

A large part of this work is devoted to diet and hygiene, a good 
deal also to the consideration of the action of medicines. For, indeed, 
I believe in medicines. Advancing years and experience during a 
period of increasing exactness in medical methods have rather 
strengthened my belief than otherwise. What the knife is to the 
surgeon, drugs are to the physician. The knife does not make the 
surgeon, nor do medicines make the physician; both, however, are 
indispensable. To employ them with benefit takes skill and experi- 
ence, both individual and collective, as also judgment and honesty. 

Indications for the administration of medicines are furnished by 
etiology and symptomatology. Both of these occupy a prominent 
place in this book. Without a diagnosis of the morbid process and 
of its evolution, and without the appreciation of its influence on the 
patient, no rational therapy can be thought of. Consequently I have 
taken particular pains to offer clear, though brief, statements of dif- 
ferential diagnoses. 

I have tried to write a book for those who are sufficiently pre- 
pared by previous studies to build their therapeutical measures on 
the foundation of an exact recognition of the conditions they have 
to deal with. It is intended for those to whom neither the principles 
of diagnosis nor the facts of materia medica are mysteries. There- 
fore, I have abstained from ornamenting my pages with numerous 
recipes. While aiming at accuracy in dosing, I have trusted, as re- 
gards the actual writing of prescriptions, to the knowledge and in- 



viii PREFACE TO THE FIRST EDITION 

telligence of the reader. On account of our present period of tran- 
sition to the metric system, I beg to be pardoned for alternating the 
old method with the new. 

In view of what I have included within the frame of this volume, 
it might almost claim the name of text-book. I prefer, however, to 
call it therapeutics only, intending to emphasize the fundamental 
truth that everything in medical science, in order to be both scientific 
and humanitarian, should be conducive to the prevention or to the 
cure of disease. 

The preparation of this book has extended over a long period. 
The first essays embodied in it were published in the Archives of 
Pediatrics of 1888. As a consequence the reader may discover occa- 
sional incongruities, which, however, he will find to be more those 
of style than of matter. 

A. Jacobi. 
no West Thirty-Fourth Street, New York, 
October, 1895. 



PREFACE TO THE SECOND EDITION 

The revision of this book was begun immediately after its publi- 
cation. The criticisms of reviewers and of correspondents have been 
carefully considered and taken advantage of. The final composition 
of the work as I now offer it represents the labor of a few months. 
In this way the drawbacks, resulting from the fact that the book 
which was commenced in 1888 was not published until 1896, were 
avoided. 

Some of the chapters are entirely rewritten; a few new ones are 
added; there is hardly one that has not been somewhat enlarged or 
otherwise changed. Indeed, every page has been scrutinized. In 
order to adapt the book more to the wants of the practitioner I have, 
while still adhering to the general views expressed in my former 
preface, been more explicit in the discussion of doses of drugs, and 
have added to the text a number of prescriptions. Altogether I 
have tried to avoid verbosity, to condense my teaching in as few 
words as possible, and thus, while conveying knowledge to the be- 
ginner in a most concise shape, to offer the well-informed medical 
man a repertory of the science and art of modern pediatrics, with 
the addition of my own views and experience. The remark made 
by critics, that the book is a personal one, I wish to deserve. 

A. Jacobi. 
no West Thirty-Fourth Street, New York, 
December 16, 1897. 



CONTENTS 



PAGE 

I. Feeding of Sick Children i 

Dietetics, no universal rules, I ; inanition, 2 ; various conditions of 
woman's milk, 3; albuminoids of woman's and of cow's milk, 4; 
fat in different milks, 5 ; ass's milk, 6 ; quantity of water in infant 
food, 9 ; sugar, 10 ; sodium chloride, 13 ; substitutes for breast-milk, 
15; germs in faeces, 17; in breast-milk, 17; boiling, sterilization, 
pasteurization, 18; drawbacks of sterilization, 21; dilution of arti- 
ficial food, 22 ; modification by Rotch, 24 ; other methods, 29 ; action 
of saliva, 30; hydrochloric acid, 31 ; meat preparations, peptones, 33; 
egg, 34', artificial foods, 35; alcohol, 35; dyspepsia, 37; vomiting, 
38; gastritis, 39; chronic gastric catarrh, 39; ulceration of stom- 
ach, 40 ; enteritis, 41 ; constipation, 42 ; rhachitis, 43 ; fever, 44 ; 
typhoid fever, 45; hereditary syphilis, cerebral, respiratory, acute 
renal diseases, 46 ; acute rheumatism, 47 ; rectal alimentation, 47 ; 
forcible feeding, 49. 

II. General Therapeutics 50 

Diagnosis, expectant treatment, 50; anatomical and physiological 
predisposition, 51; preventive treatment, 53; posture in bed, 54; 
schooling, 55 ; hygiene, 56 ; bathing, hydrotherapy, 57 ; administra- 
tion of medicines, 61 ; prescribing, 62 ; effects of medicines, 62 ; 
doses, 63 ; continuous medication, 64 ; mode and locality of admin- 
istration, 64 ; organotherapy, 65 ; rectal administration, 66 ; supposi- 
tories, 68; subcutaneous injections, 68; serotherapy, 71; anaesthesia 
by infiltration, 72; inhalation, 72; gargles, skin, 76; sinapisms, 
vesicatories, 77 ; ice, 79 ; fomentations, 79 ; depletion, 79. 

III. Treatment of the Newly-Born 81 

1. Asphyxia 81 

2. Postnatal Asphyxia and Atelectasis 86 

3. Immaturity and Prematurity 87 

4. Kephalaematoma 89 

5. Haematoma of the Sterno-Cleido-Mastoid Muscle 90 

6. Sclerema 91 

7. Bathing : 92 

8. Mamma, Mastitis, Perimastitis, Angioma 94 

9. Treatment of the Cord 96 

10. Omphalitis 99 

11. Umbilical Gangrene 99 

12. Arteritis and Phlebitis 99 

13. Puerperal Sepsis, Acute Fatty Degeneration (Buhl), Epidemic 

Haemoglobinuria (Winckel) . 101 

14. Umbilical Hemorrhage 102 

xi 



xii CONTENTS 

PAGE 

15. Icterus 103 

16. Melaena Neonatorum 104 

17. Trismus and Tetanus 106 

18. Blennorrhea 107 

19. Umbilical Fungus (Granuloma), Adenoma, Cysts 108 

20. Umbilical Hernia (Omphalocele) 109 

21. Congenital Constipation in 

IV. Diseases of the Blood and Constitution 113 

1. Anaemia 113 

Chronic anaemia, 113; food, 115; gastric catarrh, 117; insuffi- 
cient innervation, iron, 117; oxygen, arsenic, 119; change of 
place, cold water, mineral springs, 120; chlorosis, 120; digi- 
talis, 121; pernicious anaemia, 121; leucocythaemia, 122; 
pseudoleukemia, splenic anaemia, 123. 

2. Rhachitis 124 

Digestive disorders, 126; craniotabes, 129; laryngismus stridu- 
lus, 132; respiratory organs, 133; constipation, 134. 

3. Scrofulosis 135 

Preventive and curative treatment, 136; lymph-bodies, 138. 

4. Lymphatism 140 

5. Diseases of the Ductless Glands 142 

Thyroid gland, goitre, 142; cretinism, 143; exophthalmic goi- 
tre, 145 ; thymus, 146 ; acromegaly, 147 ; hypertrophic osteo- 
arthropathy, 148; Addison's disease, 148; organotherapy, 149; 
spleen, 149; splenomegaly, 150. 

6. Hemorrhagic Diathesis 151 

Werlhof's disease, scurvy, peliosis rheumatica, haemophilia, 
151 ; infantile scurvy, 153. 

7. Diabetes 154 

Diabetes mellitus, 154; insipidus, 156. 

V. Infectious Diseases 157 

1. Tuberculosis 157 

Acute miliary tuberculosis, 158; caseous pneumonia, chronic 
pulmonary tuberculosis, 158; causes, 159; inhalation of bacilli, 
161; altitude, 164; arsenic, 165; digitalis, 166; creosote, 
guaiacol, 167; ichthyol, 168; tuberculin, 168; operative pro- 
cedures, larynx, 170; tongue, pharynx, intestines, 171; fistula 
in ano, 172; hemorrhages, 172; night-sweats, 173. 

2. Syphilis 174 

Diet, prevention, 175; treatment, 176; parasyphilis, 179. 

3. Intermittent Fever 180 

4. Typhoid Fever 183 

Preventive treatment, abortion, 184; general treatment, 185; 
feeding, bronchitis, 185; high temperatures, 186; tympanites 
and meteorismus, 187; diarrhoea, 188; constipation, 188; peri- 
tonitis, perforations, hemorrhages, 189; heart-failure, 189; 
brain symptoms, 190 ; convalescence, 192 ; consecutive diseases, 
193; typho-malaria, paratyphoid, 193. 



CONTENTS xiii 

PAGE 

5. Typhus, Relapsing Fever, Weil's Disease 194 

6. Epidemic Cerebro-Spinal-Meningitis 194 

7. Glandular Fever 196 

8. Catarrhal Fever 197 

9. Asiatic Cholera 197 

10. Dysentery . 199 

11. Scarlatina 204 

Prevention, 205 ; rules of the New York Health Department, 
207; methods of disinfection, 209; disinfection and disinfect- 
ants, 210; medicinal treatment, 211 ; rheumatism, 213 ; heart, 
joints, 214; respiratory organs, hemorrhages, 214; pemphigus, 
215; complications, 215. 

12. Measles 217 

Hemorrhagic measles, respiratory organs, 218 ; kidneys, brain, 
219. 

13. Rotheln (Rubella) 219 

14. Mumps 220 

15. Variola, Variolois 221 

16. Varicella ( Chicken-Pox) 222 

17. Vaccinia 222 

18. Erysipelas 223 

19. Diphtheria 226 

Definition, 226 ; prevention, 228 ; relation to mucous mem- 
branes, 230 ; potassium chlorate, 233 ; heart-failure, 233 ; local 
treatment, 236 ; nose, 237 ; adenitis, 241 ; internal treatment, 
242; nephritis, 244; paralysis, 244; antitoxin, 245. 

20. Rheumatism 250 

Acute articular rheumatism, 250 ; heart, 255 ; gonorrhceal 
rheumatism, 257 ; rheumatismus nodosus, peliosis rheumatica, 
258 ; chronic articular rheumatism, 259 ; muscular rheumatism, 
260. 

21. Influenza '. 260 

22. Pertussis 261 



VI. Diseases of the Nervous System 268 

1. General Indications 268 

Electricity, massage, 269 ; affections of nerves and muscles, 
270 ; polyneuritis, hemicrania, muscular atrophy, progressive 
juvenile muscular dystrophy, pseudo-hypertrophy, congenital 
myotonia, 271. 

2. Operations 272 

Microcephalus, idiocy, 2^2 ; brain tumors, 273. 

3. Inflammatory and Exudative Processes, Arrests of Development. 274 

Cerebral meningitis, 274; hyperemia, 275; thromboses, embo- 
lism, 275 ; tubercular meningitis, 276 ; lumbar puncture, 279 ; 
general paresis, 279 ; chronic hydrocephalus, 280 ; disseminated 
sclerosis, infantile spastic hemiplegia, bulbar paralysis, menin- 
gocele, encephalocele, 283; meningocele spuria, 284. 



xiv CONTENTS 

PAGE 

4. Psychical Diseases 284 

Dementia, mania, melancholia, moral insanity, monomania, epi- 
leptic and circular dementia, paresis, delirium tremens, 284; 
idiocy, cretinism, 285 ; pavor nocturnus, 287. 

5. Spinal Inflammations and Arrests of Development 288 

Pachymeningitis, leptomeningitis, transverse myelitis, Landry's 
paralysis, sclerosis, paramyoclonus, 288; tabes, poliomyelitis, 
291 ; club-foot, 293 ; hydrorrhachis, 293. 

6. The Nerves 294 

Neuroma, 295; peripheral paralysis, 295. 

7. Neuroses of Central or Local Origin 295 

Eclampsia, 295 ; chorea minor, 296 ; tetany, 299 ; catalepsy, 
chorea major, hysteria, 300; athetosis, 301; epilepsy, 301; 
salaam spasm, 307 ; rotatory spasms, 308 ; stammering, 308. 



VII. Diseases of the Digestive Organs 309 

A. The Mouth 309 

1. Fraenum of the Upper Lip 309 

2. Harelip and Fissure of the Palate 309 

3. Tumors in the Oral Cavity 309 

4. Ranula 310 

5. Milia, Epithelial Pearls 310 

6. Stomatitis 311 

7. " Bednar's Aphthae" 312 

8. Thrush ' 313 

9. Noma 314 

10. Sublingual Adenitis 314 

11. Parotitis 315 

12. Difficult Dentition 315 

13. Dental Ulceration, Riga's Disease 316 

B. The Tongue 316 

1. Congenital Anomalies 316 

2. Glossitis 317 

C. The Throat 318 

1. Pharyngitis, including Amygdalitis (Tonsillitis), Hemor- 

rhage 318 

2. Retro- and Latero- Pharyngeal Abscess 320 

3. Adenoid Vegetations 322 

4. Congenital Fistula 324 

D. The (Esophagus 325 

E. The Stomach 326 

1. General Nosology, Dyspepsia 326 

2. Acute Gastric Catarrh 331 

3. Gastritis 33i 

4. Chronic Gastric Catarrh 332 

5. Dilatation of the Stomach, Stenosis of the Pylorus 333 

6. Nervous Dyspepsia 335 

7. Gastric and Duodenal Ulceration 336 



CONTENTS xv 

PAGE 

F. Intestinal Disorders 339 

1. Constipation 339 

Actual constipation, apparent constipation, 339; mechan- 
ical obstruction, 340 ; membranous enteritis, 341 ; mu- 
cous enteritis, 341 ; peristalsis, 341 ; colic, 344. 

2. Diarrhoea 344 

Causes, 344; bacteric, 346; acid, 348; acute intestinal 
catarrh, 350.; diet, 351 ; " summer" diarrhoea, 351. 

3. Tumefaction of the Mesenteric Lymph-Bodies 352 

4. Appendicitis 353 

5. Paratyphlitis 356 

6. Intussusception 357 

7. Helminthes 358 

8. Umbilical Hernia 361 

9. Inguinal Hernia 361 

10. Catarrh of the Rectum 362 

11. Prolapse of the Anus and Rectum 363 

12. Fissure of the Anus 364 

13. Polypus of the Rectum 365 

G. The Liver 366 

Enlargement, 366; hepatoptosis, 367; fatty infiltration, 
368; cirrhosis, 368; congestion, 369; inflammation and 
suppuration, acute yellow atrophy, jaundice, 370; echino- 
coccus, 371 ; cancer, 371. 

H. Peritonitis 372 

Tubercular, 374 ; chronic, 375 ; ascites, 375 ; chylosus, 376. 



VIII. Diseases of the Genito-Urinary Organs 377 

1. The Kidneys 377 

Preventive treatment, uric acid infarction, 377 ; malformations, 
pseudoplasms, primary tuberculosis, 378 ; echinococcus, hydro- 
nephrosis, floating kidney, 379; hsematuria, hemoglobinuria, 
380 ; nephritis, causes, 381 ; acute, 383 ; subacute, 384 ; chronic, 
385; renal calculi, 387; ureter, pyelitis, 388. 

2. The Bladder 389 

Cystitis, 389 ; spasm, retention, incontinence, 390, 391 ; dysu- 
ria, irritable bladder, 390 ; retention, 391 ; muscular debility, 
392 ; reflex contraction, irritability of the neck, 393 ; tumors, 

394- 

3. Other Organs : Anomalies and Diseases 394 

Development, 394 ; epithelial obstruction, membranous obstruc- 
tion, imperforation of the glans, strictures, hypospadias, pre- 
puce, 395 ; phimosis, 397 ; diphtheria of the prepuce, aphthous 
vulvitis, noma of the vulva, paraphimosis, 400; balanitis, bal- 
anoposthitis, vulvar and vaginal catarrh, 401 ; atresia, 402 ; 
imperforate hymen, vaginal hemorrhage, masturbation, 403 ; 
cryptorchis, 404 ; orchitis, tuberculosis, syphilis, hydrocele, 405 ; 
neoplasms, 406. 



xvi CONTENTS 

PAGE 

IX. Diseases of the Respiratory Organs 407 

1. The Nares 407 

Acute nasal catarrh, 407; chronic, 409; polypus, foreign 
bodies, 412; epistaxis, 413; ulceration, 414. 

2. The Larynx 415 

Acute laryngitis, 415; chronic laryngeal catarrh, 416; diph- 
theritic laryngitis, pseudo-membranous croup, 416; neurotic 
affections, spasm of the glottis, paralysis of the glottis, 420; 
neoplasms, 421. 

3. The Bronchi 422 

Bronchial catarrh, bronchitis, 422 ; chronic, 423 ; fibrinous, 
424; bronchiectasis, asthma, 424; periodic night-cough, 425. 

4. The Lungs 426 

Pneumonia, 426; hypostatic, interstitial, non-tubercular, phthi- 
sis, emphysema, 435 ; pulmonary oedema, pulmonary hemor- 
rhage, infarction, 436; gangrene, pseudoplasms, echinococcus, 
actinomycosis, hernia of the lungs, funnel chest, 437. 

5. The Intrathoracic lymph-bodies 438 

6. The Pleura 438 

Pleuritis, 438; hydrothorax, pneumothorax, pyopneumothorax, 
448. 



X. Diseases of the Organs of Circulation 449 

1. The Heart 449 

Acute and chronic diseases, 449; myocarditis, 458; endocar- 
ditis, 460; pericarditis, 463; neuroses, congenital anomalies, 
464; congenital undersize, 466. 

2. The Blood- Vessels 466 

Hypoplastic state, aneurism, 466; atheromatous degeneration, 
thrombosis, 467 ; nsevus, angioma, 468. 

3. The Lymph- Vessels 470 

Lymphangioma, elephantiasis, chyluria, cystic lymphangioma, 
470. 



XI. Diseases of the Skin 47: 

Burns, 471 ; frost-bites, emphysema, erythema, 472 ; erythema 
nodosum, 474 ; intertrigo, acne, lichen, prurigo, 475 ; lichen 
scrofulosorum, 476 ; furunculosis, 477 ; eczema, impetigo, 
ecthyma, rupia, 478; eczema seborrhoicum, pemphigus, 480; 
dermatitis exfoliativa, pemphigus foliaceus, pemphigus exfo- 
liativus, neuropathic affections, papillomata, 481 ; pemphigus 
neuroticus chronicus, oedema, cyanosis, 482 ; symmetrical hem- 
orrhage, erythromelalgia, gangrene, scleroderma, 483 ; herpes, 
scabies, 484 ; impetigo contagiosa, favus, herpes tonsurans, 
485 ; molluscum contagiosum, lupus, 486 ; lupus erythematosus, 
486; tuberculosis of the skin, scrofuloderma, psoriasis, con- 
genital diseases, 487; ichthyosis, 488; neoplasms of the neck, 
nsevus pigmentosus, verrucosus, lipomatodes, 489. 



CONTENTS xvii 

PAGE 

XII. Diseases of the Muscles 491 

Myositis, 491 ; paralysis, pseudo-paralysis, 492 ; myasthenia, 
torticollis, 493. 

XIII. Diseases of the Bones and Joints 495 

1. Congenital Anomalies 495 

Exostoses, 495. 

2. Congenital Luxations 496 

3. The Bones 498 

Fractures, 498 ; chondritis, osteitis, 499 ; spondylitis, 501 ; 
arthritis deformans, 502. 

4. The Joints 503 

Surgical tuberculosis, 505; coxitis, 509; gonitis, ankle- and 
tarsal- joints, elbow, genu valgum, 510, pes varus 511 ; equinus, 
calcaneus, 512; valgus, 513 ; scoliosis, 513 ; kyphosis, 515. 

XIV. Diseases of the Ear 516 

Malformations, foreign bodies, otitis externa, 516; myringitis, 
517; polypus, 518; otitis media, 519; mastoid process, 522; 
deaf-mutism, 523 

XV. Diseases of the Eye 524 

Malformations, neoplasms, 524; foreign bodies, 525; injuries, 
blepharitis, conjunctiva, 526; conjunctivitis, 527; diphtheritic, 
gonorrhceal trachoma, 528 ; keratitis, 529 ; keratoconus, iritis, 
531 ; cyclitis, vitreous body, choroid, cataract, retina, optic 
nerve, orbit, 532 ; glaucoma, strabismus, nystagmus, 533. 



THERAPEUTICS 

OF 

INFANCY AND CHILDHOOD 



i 

Feeding of Sick Children 

Dietetics should be considered a part of therapeutics. The two 
must always go hand in hand. Ancient physicians knew the fact 
that many diseases are removed by a correct mode of living and nutri- 
tion; and the men who established therapeutical schools on certain 
positive principles or on preconceived ideas arranged their dietetical 
and their medicinal and surgical rules on the same basis. Thus, 
Broussais, among others, while he purged and bled, crowned his 
work with starvation to such an extent that Graves, in 1843, had to 
come forward with the declaration that the systematic starvation of 
the disease ended in the destruction of the patient. It was Chossat, 
finally, who proved that inanition had many of the symptoms of 
fever, and that a starvation diet was liable to increase the dangers 
of an illness. 

Still, there are no universal rules for feeding, as there are none 
for medication. There are, however, certain indications which can 
always be fulfilled in the treatment of individual cases. As intellect 
and knowledge are required for finding these indications, so there 
is need of tact and experience to apply and fulfil them. Some of 
them are plain enough. It is clear that in conditions of great debility 
there must be no further reduction of strength ; an irritated cerebrum 
should not be excited ; hemorrhages, peritonitis, dysentery, perityph- 
litis, require absolute rest ; a hyperaesthetic stomach must not be over- 
fed ; a gastro-enteritis resulting from the presence of ferments should 
do without milk ; convalescence should be shielded and acute inflam- 
matory fevers guarded. Still, there are chronic fevers with fair 
digestion which permit of generous feeding. All these indications 
and rules are equally valid for both the adult and the young. But 



2 FEEDING OF SICK CHILDREN 

the latter have some peculiarities which alter the application of gen- 
eral rules to a considerable extent, for several reasons. Of these I 
shall mention but a few at this time. Habits, which play an all- 
important part in the nosology of adults, such as alcohol, narcotics, 
sexual abuses, are not observed — unless very exceptionally — in the 
child. Cardiac debility, which is the constant danger of the senile 
period, and a frequent one in the adult, is in the beginning of a 
morbid process not so frequent in the very young, partly because the 
heart, compared with the rest of the body, is larger and more power- 
ful, and partly because it has not had so much time and opportunity 
to become diseased. On the other hand, general metamorphosis is 
very rapid in the young, because both of the rapidity of the vital 
processes and of the constant necessity of adding to the tissues of 
the body, besides keeping up the equilibrium. Therefore inanition 
through insufficiency or incompetency of food is not tolerated for a 
long time. The very fever referred to above appears to depend on the 
absorption and elimination of albuminoids, both those which are stored 
in the tissues and those which are circulating in the blood, and of 
the disintegrated carbohydrates. Thus the child cannot long remain 
without being fed, and, therefore, its digestive organs require per- 
manent attention. Their physiology must be carefully studied both 
in the healthy and morbid conditions. What the child eats is impor- 
tant, but of little consequence compared with what it digests. Nor 
are its subjective sensations the proper guides for the selection of 
foods or for the times of feeding. It is not always true that when 
there is no appetite there is no digestion. Nor are the pangs of 
hunger or the temptations of whimsical cravings safe counsellors. 
Nor does the condition of the tongue, to which we are apt to turn 
as one of our advisers in many of the ailments of the adult, deserve 
the same confidence in the young, for the frequent local processes 
in their oral cavities are apt to mislead us in regard to their signifi- 
cance. 

The feeding of sick infants and children must be a modification 
of their normal feeding only, in the same way that their ailments and 
diseases are only modifications or changes brought about by abnormal 
influences in their physiological conditions. That is why the question 
of normal feeding for both infants and children should be the first 
to be answered. Then only the duty of altering the normal food to 
meet the requirements of aberrations from the usual healthy condition 
is to be taken into consideration. 

For the newly-born and the infant the proper food is his mother's 
milk, if any be secreted, both in health and illness, or the milk of 



VARIOUS CONDITIONS OF WOMAN'S MILK 3 

some other woman if there be no mother or no maternal breast, 
always provided it agrees with him. For milks are not identical. 
A baby may thrive on the milk of one woman and not on that of 
another ; and the constituents of woman's milk are only " more or 
less constant" (Monti). Johannessen and Wang (Zeitsch. f. phys. 
Chemie, vol. xxiv. ) found in breast-milk the following differences : 
albumin 0.9 to 1.3 per cent., fat 2.7 to 4.6 per cent., sugar 5.9 to 7.55 
per cent. They also found the amount of sugar to be less, but that 
of albumin and of fat larger towards the end of nursing, and the fat 
to reach its minimum in the course of the night. Indeed, the tens 
of thousands of recorded analyses of woman's milk are contradictory ; 
no two are alike. Besides, a woman's milk will change during nursing 
from minute to minute, from morning to night, by variety of food, 
state of health, menstruation, lactation, emotions, etc. But, after all, 
human milk is the food for the human young. Modifications, how- 
ever, are indicated during illness. As a rule, the quantities of food 
supplied during illness should be less because less is digested ; feverish 
diseases require less substantial food and more water; in fact, water 
may have to replace the former altogether temporarily ; indeed, there 
are conditions in which even woman's milk is not borne at all. In 
gastritis no food and no water are tolerated ; in enterocolitis milk may 
not be permitted, and cereal decoctions or a mixture of egg albumin 
and water may have to take its place. 

Such and similar changes, if required even for those who are fed 
on the most normal substance, are demanded when artificial feeding 
has to take the place of breast-milk. Now, the majority of our babies 
are in that position, either from birth or soon after, and the question 
of the methods of procuring the most advisable food for infants has 
for that reason engaged the anxious attention of the profession. 
Whatever is the best artificial food in health is the best in disease, 
with such modifications as are required by the changed physiological 
conditions. 

No artificial food for the infant can be thought of except the 
milk of some animal, — viz., the cow, — which is the only one that is 
accessible in the vast majority of cases, with the exception of the 
goat, or the ass, in some localities. That is why a brief consideration 
of the physical and chemical properties of cow's milk, compared with 
those of human milk, should precede the discussion of the mode of 
its administration, whether pure or mixed or modified. 

The differences between the casein of woman's and of cow's milk 
have been studied extensively since Hammarsten (one-third of a cen- 
tury ago), but to this moment it is not clear whether the albuminoid 



4 FEEDING OF SICK CHILDREN 

which is found (more in the woman than in the cow), besides casein, 
is coordinate to it or derived from it, and the result of disintegration. 
Koplik even asserts that woman's casein contains an additional albu- 
minoid which is not identical with either the known casein or albumin 
(N. Y. Med. Jour., April 13, 1895). In Immanuel Munk's opinion 
(Virch. Archiv, vol. cxxxiv.), the part played by nitrogen in the albu- 
minoids of woman's and cow's milk is different. There is more syn- 
tonin in cow's milk casein and more lime (6.6 per cent, compared 
with 3.2 per cent, in woman's milk — Lehmann), more phosphorus in 
woman's milk (0.84) than in cow's milk (0.68), less sulphur in 
woman's milk (0.75) than in cow's milk (1.11). ''Lab" ferment 
coagulates cow's milk in coarser lumps than it does woman's milk, 
and the nature of this coagulation depends also on the introduction 
of milk-sugar, of fat, of sodium chloride, or of dextrinized or other 
flours. 

According to Schlossmann, of the albuminoids in woman's milk 
sixty-three per cent, are casein, thirty-seven per cent, lacto-albumin, 
which being directly absorbable constitutes an essential difference 
from cow's milk; all of the latter has to be transformed during the 
digestive process before it can be assimilated. 

The casein of woman's milk is not so easily thrown out by acids — 
for instance, lactic acid or salts — as that of cow's milk, and is more 
readily dissolved in an excess of acid. Some years ago Wroblewski 
demonstrated the difference in solubility of the two milks. Woman's 
casein retains, during pepsin digestion, its nuclein (proteid rich in 
phosphorus) in solution: it is fully digested; in cow's casein the 
nuclein is not fully digested : a " paranuclein" is deposited undissolved 
and undigested. 

K. Wittmaack and M. Siegfried published lately (Zeitsch. f. phys. 
Chern., vol. xxii.) their essays on the nucleon (the phosphoric acid of 
muscle) in the milks of cow, woman, and goat, and on phosphorus 
in the milks of the cow and the woman. Their conclusions are accepted 
by E. Salkowski as correct, which, I should say, proves them to be 
so. Cow's milk contains 0.057, goat's milk 0.110, and woman's milk 
0.124 per cent, nucleon. In cow's milk the phosphorus of the nucleon 
amounts to six per cent, of the total amount of phosphorus contained 
in the milk; in woman's milk 41.5 per cent. That means that in cow's 
milk not one-half of its phosphorus is in the organic combinations 
of casein and nucleon ; in woman's milk almost all of it. In cow's 
milk the phosphorus not utilized for organic combinations is con- 
tained in the inferior phosphates. E. Salkowski adds the following 
remarks : " These conditions are evidently of the greatest moment 



WOMAN'S AND COW'S MILK. CASEIN. FAT 5 

in the nutrition of the nursling. As the development of bones is more 
readily accomplished in nurslings fed on woman's milk than in those 
fed on cow's milk, the probable conclusion is this : that nucleon has 
an important part in the absorption and assimilation of phosphorus. 
The same should be said of calcium, which also combines with nu- 
cleon. Though woman's milk contains less calcium than cow's milk, 
more calcium is utilized out of the former, and the nucleon is evidently 
an important factor in its absorption also." 

A certain amount of fat is digested even in fevers of moderate 
severity, thus also in typhoid fever. But it is a good rule to rather 
reduce its quantity, because when infants were fed on cow's milk 
during capillary bronchitis, the fat in the faeces amounted to forty 
per cent, of the solid constituents. A few additional remarks will 
render the subject clearer, and show that it is very easy to give too 
much fat. 

Infant faeces are comparatively copious, although the baby receive 
absolutely nothing but mother's milk. What has been called detritus 
in the faeces is not exclusively undigested casein, but principally fat 
and large masses of intestinal epithelium; for this so-called detritus 
is not soluble in water, acids, or alkalies, but quite soluble in alcohol 
and ether. Casein is present only when it has been taken in too large 
a quantity, or when there is too much free acid in the stomach. In 
those cases there are large quantities of it in the faeces. The normal 
faeces of the infant, according to Wegscheider, contain nine per cent, 
of fat ; according to Heubner, nearly six per cent. ; according to the 
same authority, the infant with " weak intestines" would expel fifteen 
per cent, of the fat introduced into the stomach. Besides, W. Knop- 
felmacher (Wiener med. Woch., No. 30, 1897) found that the fat of 
the faeces of the adult and advanced child while they were fed on milk 
consisted of from twelve to twenty per cent, of olein, of which the 
larger portion came from the digestive juices, the smaller from the 
unabsorbed fat of the milk. The fecal fat of the nursling, however, 
contained from 28.8 to 37.8 per cent, olein, only five per cent, of which 
was due to the digestive juices ; all the rest belonged to the unab- 
sorbed milk fat. Thus, we may conclude that the latter is less utilized 
by the nursling than by the adult. 

One of the reasons for adding fat (cream) to cow's milk to make 
it a more appropriate food for the infant was its alleged low per- 
centage in fat. Still, in a large number of analyses, though they differ 
ever so much, the percentage of the two milks is by no means very 
dissimilar. Soldner has 3.28 per cent, of fat in woman's milk ; Marfan, 
who draws the average from the results of a number of analytic 



6 FEEDING OF SICK CHILDREN 

chemists, gives us 3.7 per cent, for cow's and 3.8 per cent, for woman's 
milk. In the face of such facts the addition of fat (cow's cream) 
to cow's milk to make it more similar to woman's milk does not appear 
very rational. 

Moreover, the fat of cow's milk differs from that of woman's milk. 
The latter has more oleic acid, less volatile acid than cow's milk; 
woman's milk holds its fat in a finer emulsion and contains from 
two to four times as many fat-globules as are counted in equally 
fat cow's milk (Schlossmann). This condition makes it more digesti- 
ble; it is assumed, and reasonably so, that the fine fat-globules may 
be absorbed directly through the epithelia or of the intestinal villi. 
Moreover, cow's milk fat undergoes changes before it is used. When 
cream is taken after slow rising it is apt to acidulate, when sterilized 
and centrifuged it is changed chemically and physically, when frozen 
it separates from the milk and does not mix again. 

All of these facts and considerations and the low percentage in 
fat of ass's milk, which was known to agree best with nurslings and 
to be inferior to woman's milk only (according to Vernois and Bec- 
querel's analyses made fifty years ago), have led me to reduce rather 
than to increase the fat of cow's milk used for infant feeding. I 
meet with no fat diarrhoea and no excessive acidity when babies are 
fed according to that rule. 

H. von Ranke's recent favorable experiences with ass's milk (Fest- 
schrift in honor of A. Jacobi, New York, 1900) administered to young 
infants, one of whom did not thrive at all previously, Klemm's report 
(Dresden, 1898) on ass's milk employed for two or three months, 
Marfan's corroborative opinion (" Allaitement," p. 299), and the ear- 
lier results of Parrot and West leave no doubt as to the favorable 
effect of ass's milk, with its low percentage of fat, at all events in the 
first few months of infant life. Ass's milk is digestible and whole- 
some not in spite, but because of its low percentage of fat, and in spite 
of its albuminoid being contained in larger quantities in ass's than in 
woman's milk.* 

What is proven for babies in the first months I also claim for 
older infants. For them some fat may be added to ass's milk, per- 
haps, while the stools are being watched for undigested cream, but 

* According to Bnnge (Phys. Chemie, 4th ed., 1899), there is in the milk of 



Albuminoid 

Fat 

Ash 



Women. 


Cows. 


Asses. 


Per cent. 


Per cent. 


Per cent. 


1-7 


3-5 


2-3 


3-8 


3-7 


1.6 


0.2 


0.7 


o.S 



FAT IN WOMAN'S AND COW'S MILK y 

I know that they do better with less fat than under the influence of 
laboratory analyses, no two of which are alike, is generally con- 
sidered their due. I insist that a series of clinical observations made 
prudently and critically and extensively must and will be esteemed 
as equivalent to the results of measures and scales and microscopes ; 
I say equivalent, neither superior nor inferior, for there is no more 
virtue in the limited and boastful experimenter than in the one-sided 
and narrow practitioner. That is why to me it has been a source 
of great satisfaction to notice that in the writings of the last few 
years clinical experience is frequently appealed to and called in as 
evidence; and from that point of view I again appeal to the medical 
profession to revise theories and practices that I firmly believe to be 
wrong and dangerous. 

An important practical application of this fact is the following. 
As it is true that fat is not completely absorbed, even under the most 
normal circumstances ; as free fat acids are so easily formed and 
accumulated ; as they are found in moderate quantities, even in healthy 
babies ; as a surplus is very apt to derange digestion and assimilation 
and prevent the normal secretion of either of the digestive fluids ; 
as there is a superabundance of fat in the normal food of the nursling, 
the conclusion is justified that we should be very careful in preparing 
foods for the healthy or sick. It is very easy to give too much fat. 
It is hardly probable that there is too little. 

V. and I. S. Adriance have succeeded in proving, by exact chemi- 
cal and clinical researches, some facts which were known, but perhaps 
not sufficiently appreciated. Both excessive fats and proteids in the 
milk of the mother may cause gastro-intestinal symptoms in the 
nursing infant ; the former may be reduced by diminishing the nitrog- 
enous elements in the mother's diet ; the latter by the proper amount 
of exercise. Excessive proteids are especially apt to cause gastro- 
intestinal symptoms during the colostrum period, and particularly 
during that of premature confinement, when their percentage is higher. 
Premature infants are, therefore, in particularly great danger, and 
their food ought to be greatly modified and watered. 

Under the head of " Fat Diarrhoea," German journals and a few 
text-books speak of a diarrhoea the chief characteristic of which is 
the presence of a large quantity of fat in the stools. 

The normal faeces of the newly-born exhibit ten or twelve per 
cent., sometimes more, of fat. In abnormal cases, even when the food 
does not contain it, the faeces may show from forty to seventy per 
cent, of fat. 

In serious cases the microscope reveals fat, almost to the exclu- 



8 FEEDING OF SICK CHILDREN 

sion of everything else, sometimes pure, and other times in more 
or less regular needles. The anatomical condition in fat diarrhoea 
may vary, but in the majority of cases we have to deal with a simple 
catarrh of the intestinal tract. There are changes in, and exfoliation 
of, the epithelium of the small intestine, swelling of the mucous mem- 
brane of the duodenum, with obstruction to the flow of the secretions 
of both liver and pancreas, and such hyperplasia of the mesenteric 
lymph-bodies as to impede the absorption and circulation of chyle. 
Finally, in a very few instances, anatomical changes were found in 
the pancreas resembling those which in the adult interfere with the 
emulsion of fat. In such cases the use of pancreatin appears to be 
indicated. 

No improvement is possible unless the quantity of fat con- 
tained in the food be largely diminished. The administration of 
cream and the routine treatment with cod-liver oil are equally in- 
jurious in these cases; for even normal digestion disposes only of 
a limited quantity of fat (cream, butter, cod-liver oil) ; twenty- 
five per cent, of it in the food, as lately recommended (Berliner 
klinische Wochenschrift, June 14, 1897), is excessive. One of the 
preparatory stages of its assimilation is the formation of oleic acid; 
lipanin, which has been recommended in place of cod-liver oil, 
contains six per cent, of that acid, the physiological preparation 
of which the body is spared by its administration. There may be 
very few conditions in which the digestion is so low as not to in- 
sure the required transformation, but in chronic dyspepsia of different 
sorts fat is badly digested and absorbed, and lipanin may take its 
place. 

An excess of fat in infant foods is considered faulty, if not dan- 
gerous, by almost every author, though Schlossmann pronounces the 
belief in the injuriousness of fat to be "antiquated." (Nor is the 
assertion of Voit, that the carbohydrates, by their power to prevent 
the loss of fat and albumin in the tissues, may take each other's 
places, so that fat, sugar, or sweets could be mutually substituted, 
justified by experience.) What I have wished to impress, however, 
is that an apparent lack of cow's milk cream is by no means 
a fault. Practical experience proves its good results, and its low 
percentage in a mixture which is greatly diluted is in reality only 
apparent. The diluting element is mostly water, which when con- 
taining salts and sugar is readily absorbed even in the stomach, and 
for that reason is no disturbing element in the relative proportion of 
the constituents of the artificial food. 

Infants' food ought to be mixed with large quantities of water, not 



WATER IN INFANTS' FOOD 9 

for the sick only, but under ordinary circumstances. In diseased con- 
ditions of the stomach when pepsin and hydrochloric acid are wanting 
the free dilution of children's nourishment with water is demanded 
upon the following physiological facts. Only to a certain limit, if at all, 
will pepsin be furnished for digestive purposes. Probably a portion 
of this is not entirely utilized, because a great quantity of water is 
necessary to assist in pepsin digestion. In artificial digestion albumin 
often remains unchanged until large quantities of acidulated water 
are supplied. Without doubt many disturbances of digestion are 
to be explained by a deficiency of water, certainly many more than 
are due to an apparent excess of it, for the latter, particularly when 
containing salts or sugar, is speedily relieved by rapid absorption. 

For the reasons given, I advocate under all conditions a plentiful 
addition of water to children's food. As a general observation, I 
would lay stress upon the fact that, as a rule, small children receive 
water only as they get it in their milk or milk food. Alike in summer 
and in winter, it is probable that the fact seldom occurs to a mother 
or nurse that a child may be thirsty without being hungry at the 
same time. Certainly, many a discomfort and even sickness in a 
child is conditioned upon the fact that it has been compelled to eat 
in order to satisfy its thirst, and often has to suffer thirst because the 
overstimulated and injured stomach will take no more nourishment 
at irregular and too short intervals. There are even normal products 
of digestion that are capable of disturbing the digestive process, chief 
among which is peptone itself, which is not absorbed unless it be 
greatly diluted. That is why I, when preparing the rules for the 
feeding of children, which the New York Health Department annually 
published and distributed through several decades, insisted upon 
giving infants, who cannot ask for it in so many words, an occasional 
drink of water, particularly during the hot weather. When there is 
the least ground for the supposition that the drinking-water is con- 
taminated with germs of disease, or when it is unusually hard, it 
should be boiled before its admixture with children's food, whether 
the diet be milk or a mixed one. In general it will be most satisfac- 
tory to give very young infants boiled water as a matter of course, 
even though there be no apparent urgency for it. 

There are many other indications for the administration of water 
in the diseases of the young. In many morbid conditions it is want- 
ing. Perspiration, diarrhcea, general inanition, feverish diseases, 
diminish its quantity in the tissues and in the blood-vessels. Thus 
an inspissation of the blood takes place ; thromboses form in the small 
veins of distant parts or the viscera ; in the brain they lead to convul- 



to FEEDING OF SICK CHILDREN 

sions and defective innervation (hydrencephaloid), in the limbs to 
oedema or gangrene. The remedy is water in sufficient quantities. 
When the stomach rebels, the hungry lymph-ducts of the rectum will 
greedily absorb an ounce or much more, injected every hour or 
two. In many a case life is saved in this manner. In extreme cases 
the subcutaneous infusion of a sterilized salt-water solution (6 to 
iooo) is required. From two to six hundred cubic centimetres 
(six to twenty ounces) will readily be absorbed in the subcutaneous 
tissue. 

When general metamorphosis is slow, water in abundance in- 
creases the elimination of urea and carbonic acid. When the urine 
is scanty and of too high a specific gravity, water protects the kidneys 
from undue irritation. It acts on the mucous membranes as it does 
on the external integuments. In laryngitis and bronchitis it liquefies 
viscid expectoration, in many forms of constipation it acts beneficially 
by increasing the secretion of the muciparous glands of the intestines. 
Ice and ice-water, or iced carbonated water, in small quantities, but 
frequent doses, relieve hyperesthesia of the stomach and stop vomit- 
ing. Warm water acts as an emetic, hot water injected into the 
rectum combats collapse. In connection with this subject, however, 
I may allude to what good may be done by abstinence from water. 
In some forms of acute gastro-enteritis, where vomiting and diarrhoea 
are excessive, the only salvation is in total abstinence for from four 
to eight or ten hours. Not infrequently the turning-point in the 
course of the threatened danger dates from the commencement of 
what appears to be cruel starvation. 

A regular addition to the milk food of infants and children is that of 
sugar. Its percentage in the milk of the woman, ass, and mare is 
larger than in that of the cow. Immediately after the milking of the 
cow the milk-sugar begins to change into lactic acid. This process, 
after rennet has exerted its coagulating effect, together with the grad- 
ual conversion of fat into acid, is the final cause of curdling. The 
large amount of sugar (after the first week of life) in woman's milk, 
together with its smaller percentage of casein (about one per cent.) 
and butter, gives it the peculiar bluish color and furnishes the colos- 
trum of the first days after birth — which contains plenty of salts 
besides — its tendency to loosen the bowels. This property becomes 
manifest, sometimes under abnormal circumstances. Thus in the 
milk of anaemic women sugar is occasionally found to an unusual 
degree. In their cases the other solid matters may, however, be 
diminished; still, this is not uniformly so. In such instances the 
infants are liable to suffer from obstinate diarrhoea. 



SUGAR II 

The conversion of milk-sugar into lactic acid takes place very 
rapidly. Under its influence cow's milk turns sour at once. Not 
infrequently, however, it is acid from the first: it has been found to 
be so in the udder; in most cases it is " amphoteric," neutral. Thus 
the question arises what kind of sugar is to be used as the addition 
to the food of children both well and sick, provided the milk-sugar 
of woman's and that of cow's milk be identical, which is very doubtful, 
and provided further that the milk-sugar in the market be not, as 
it frequently is, impure. That alone makes it desirable, or rather 
advisable, to substitute cane-sugar for milk-sugar if the former afford 
the same advantage. These four dozen years I have made this sub- 
stitution. For their absorption is about as easy, even in the stomach, 
as that of dextrin, peptone, and salt solutions. 

Most of the milk-sugar of the milk is changed into lactic acid by 
the bacterium lactis aerogenes and a number of other bacilli. When 
eight-tenths of one per cent, of the milk-sugar contained in the whole 
milk in the stomach is changed into lactic acid, no more lactic acid 
is produced. Ordinarily, however, this limit is reached when about 
one-fourth of the milk-sugar has been changed into lactic acid. If 
at this period, however, lactic acid be neutralized by an alkali, 
then more milk-sugar is changed into lactic acid. In this way 
the amount of lactic acid present in the digestive tract depends on 
accidents only, — that is, mainly on the presence or absence of an 
alkali, — and it appears that in every preparation containing cow's milk 
that is selected for the use of an infant there is milk-sugar enough 
to supply the needs of the digestion of the whole ingesta. Moreover, 
a goodly part of the milk-sugar introduced, even in woman's milk, 
is eliminated unchanged, for Blauberg (" Studien iiber Sauglings- 
faces," p. 55) found the nursling's desiccated faeces to contain from 
0.22 to 0.59 per cent, of milk-sugar. Escherich found that peptones 
which form in milk previous to normal absorption are destroyed by 
acid fermentation, and concludes that for that reason another carbo- 
hydrate should take the place of milk-sugar in order to avoid the 
excess of lactic acid. 

It appears after all this that it is easier to give too much milk- 
sugar than too little, and that the careful measuring and weighing 
of copious quantities of milk-sugar are of doubtful value, even if 
you know, or believe you know, that the milk-sugar you give and 
the milk-sugar of woman's milk are identical. Immediate fermenta- 
tion in the intestine, moreover, should be carefully avoided for other 
known reasons. Lately Dr. Helen Baldwin has published {Journal 
of Experimental Medicine, vol. v.) investigations which prove the 



12 FEEDING OF SICK CHILDREN 

formation of oxalic acid as the result of intestinal fermentation. It 
appears, therefore, that my method of adding to the cow's milk 
mixtures destined for infants and children, not milk-sugar but cane- 
sugar, in moderate quantities estimated rather than anxiously weighed, 
was correct and justified by modern research. 

Cane-sugar is not so easily transformed. Indeed, it is utilized 
for the purpose of counteracting the rapid conversion of milk-sugar 
and for the preservation of articles of food in general. Trade is not 
so slow in availing itself of the results of organic chemistry as the 
profession. Condensed milk remains unchanged a long time, on 
account of the plentiful addition of cane-sugar, in spite of the original 
presence of milk-sugar in it. That is why condensed milk, though 
not an ideal food or food constituent at all, is still a beneficent make- 
shift for something better among the hundreds of thousands in 
our large cities to whom good milk, or approximately good milk, 
is inaccessible. Many manufacturers of proprietary foods employ 
grape-sugar instead of milk-sugar, reminding us that every sugar 
is changed into grape-sugar. Cane-sugar is most accessible, serves 
the same purpose, and is of the same composition as milk-sugar 
(QaHaaOn + H 22 0). Therefore it is not at all an indifferent mat- 
ter whether milk-sugar or cane-sugar be added to the food of infants 
and children. I have always insisted upon the selection of the latter 
for that purpose. Biedert employs cane-sugar in his cream mixture, 
Marfan sees " no inconvenience" in using it. 

Joseph Prechtl (Jahrb. f. Kinderh., vol. liii., 1901) doubts the 
propriety of adding milk-sugar to infant milk, for the reason that it 
coagulates the casein of the cow's milk. In the latter, casein is kept 
in solution by calcium phosphate, which is decomposed by lactic 
acid. The result of this chemical decomposition is the throwing out 
and the coagulation of casein. Normally, cow's milk contains three 
times as much casein as does human milk and much less milk-sugar 
(3 to 5 or 6). In this relative proportion cow's casein remains in 
solution. When this proportion is disturbed by adding an undue 
quantity of milk-sugar to cow's milk (say as much as is contained 
in woman's milk) the lactic acid formed out of it makes its casein 
indigestible through coagulation. The proper quantity of milk-sugar 
(which is always insisted upon by professional dietarians) to go with 
a cow's milk mixture ought to be the relative quantity met in cow's 
milk which keeps cow's milk in solution, and not the percentage of 
milk-sugar as contained in woman's milk which is in excess in its 
relation to cow's milk casein. It is only woman's casein that, though 
in a percentage three times smaller than that which is contained in 



SUGAR. SODIUM CHLORIDE 



13 



cow's milk, is not thrown out by its larger quantity of (milk-sugar- 
born) lactic acid. 

All of which proves that the casein of the cow and the casein of 
the woman are chemically different, and that the practice of adding 
the weight of milk-sugar required to keep woman's casein in solution 
is in excess of that which is tolerated by that of the cow. 

In the sick the absorption of sugar is slower than in the healthy. 
Besides, during most diseases, particularly those of the alimentary 
canal, there is more abnormal ferment in the mouth and stomach. 
Thus but little sugar ought to be given, and never in a concentrated 
form. Grape-sugar and dextrin are absorbed equally. Cane-sugar, 
according to Pavy, is partly inverted into grape-sugar and partly 
absorbed. All appear to be changed, when given in moderate quan- 
tities, into carbonic acid and water, even during moderate fevers. 

Large quantities of milk-sugar cause diarrhcea ; that is why it has 
been recommended as a purgative, and why dyspeptics bear so much 
less of it than even the healthy. Cane-sugar does not have the same 
effect to the same extent, but in that form of constipation of small 
infants which depends on a relative absence of sugar and superabun- 
dance of casein in the breast-milk, the addition of sugar acts very- 
fa vorably. A piece of loaf-sugar (a teaspoonful or less) dissolved 
in tepid water (or oatmeal water) should be given before each nursing, 
and will often prove the only remedy required to regulate the bowels. 
On account of this gently purgative effect cane-sugar is frequently 
given by the attendants to the new-born in warm water or in some 
warm aromatic tea. Such a medication is rarely demanded, for meco- 
nium is not often so solid or the mucus of the colon so inspissated 
as to require dilution. Still, there are occasional indications for inter- 
ference. But A. Keller declares sugar to be by no means indifferent 
or uninjurious, and advises saccharin instead, " to which there can be 
no serious objection." Nothing but " tea" with saccharin should be 
given the first day of life, because " Jansen made experiments on 
newly-born calves with boiled milk, which almost always resulted in 
hemorrhagic diarrhoea" ( !). 

The physiological effect of sodium chloride is very important, 
no matter whether it is directly introduced through the mother's milk 
or added as a condiment to cow's milk or to vegetable diet. Both of 
the latter contain more potassium than sodium, and neither ought ever 
to be given, to the well or sick, without the addition of table salt. 
A portion of that which is introduced may be absorbed in solution ; 
another part is, however, broken up into another sodium salt and 
hydrochloric acid. Thus it serves directly as an excitant to the secre- 



14 FEEDING OF SICK CHILDREN 

tion of the glands and facilitates digestion. Therefore, during dis- 
eases in which the secretion of gastric juice is interfered with, or in 
the beginning of convalescence, when both the secreting faculties and 
the muscular power of the stomach are wanting, and the necessity 
of resorting to nitrogenous food is apparent, an ample supply of salt 
ought to be furnished. The excess of acid which may get into the 
intestinal canal unites with the sodium of the bile in the duodenum, 
and assists in producing a second combination of sodium chloride, 
which again is dissolved in the intestines and absorbed. Its action 
in the circulation is well understood: it enhances the vital processes, 
mainly by accelerating tissue-changes through the elimination of more 
urea and carbonic acid. 

A very important fact is also this: that the addition of sodium 
chloride prevents the too solid coagulation of milk by either rennet 
or gastric juice. Thus cow's milk ought never to be given without 
table salt, and the latter ought to be added to woman's milk when it 
behaves like cow's milk in regard to solid curdling and consequent 
in digestibility. 

Habitual constipation of children is also influenced beneficially, 
for two reasons : not only is the food made more digestible, but the 
secretions of the alimentary canal, both serous and glandular, are 
made more effective by the presence of sodium chloride. 

What is it that a sick infant or child ought to eat? That question 
is so grave because the young when quite well are easily disturbed 
in their health by mistakes in their diet; indeed, the large majority 
of, the diseases of infancy are those of the alimentary canal ; and an 
error in diet during the course of a disease is liable to prove fatal. 
Advanced childhood is not so endangered; that is why my first 
remarks are due to infancy. If the literature dedicated to its phys- 
iological and pathological conditions were as profitable as it is co- 
pious, the gain would be immense by this time. For, indeed, the 
hygiene and the pathology and therapeutics of early age do not lack 
contributions. Particularly the former, being the main prop and staff 
of infant (as of all) therapeutics, has roused the zeal and industry 
of many workers, among them some of the very best of modern 
times. 

In feeding the sick, no new principles must be sought for. The sick- 
child is still the child, and the physiological laws hold their own under 
changed circumstances. No new articles of food can be discovered 
or invented, only the preparation or mixture of those in ordinary 
use may change temporarily, or a restriction in their number or 
amount may take place. Thus, I cannot undertake to give in full the 



SUBSTITUTES FOR BREAST-MILK 1 5 

methods of feeding infants and children. In several previous publi- 
cations I have done so, and must refer to them. I will only repeat a 
few rules, leaving the reasons for them to the thoughtfulness or the 
recollection of the reader. 

The principal substitutes for breast-milk are those of the cow 
and the goat. The mixed milk of a dairy is preferable to that of 
one cow. Cow's milk must be boiled before being used. Condensed 
milk is not a uniform article, and its use precarious for that and other 
reasons ; still, to a great extent, under our present social conditions, 
unavoidable. Goat's milk contains too much casein and fat, besides 
being otherwise incongruous. Skimmed milk obtained in the usual way, 
by allowing the cream to rise in the course of time, is objectionable, 
because such milk is always acidulated. The caseins of cow's and 
woman's milk differ both chemically and physiologically. The former 
is less digestible. There ought to be no more than one per cent, of 
casein in every infant food. Dilution with water alone may appear to 
be harmless in many instances, for some children thrive on it. More, 
however, appear only to do so; for increasing weight and obesity 
are not synonymous with health and strength. A better way to dilute 
cow's milk, and at the same time to render its casein less liable to 
coagulate in large lumps, is the addition of decoctions of cereals or, 
as Biedert says, dextrinized flours (malt). It will be shown that 
a small amount of starch is digested at the very earliest age. But 
cereals containing a small percentage of it are to be preferred. Barley 
and oatmeal have an almost equal chemical composition ; but the 
latter has a greater tendency to loosen the bowels. Thus, where there 
is a tendency to diarrhoea, barley ought to be preferred; in cases of 
constipation, oatmeal. The whole barleycorn, ground for the pur 
pose, should be used for smal'l children, because of the protein being 
mostly contained just inside and near the husk, and perhaps also on 
account of its fair percentage of iron. The newly-born ought to 
have its boiled milk (sugared and salted) mixed with four or five 
times its quantity of barley-water, the baby of six months equal parts 
Gum arabic and gelatin may also be utilized to advantage in a similar 
manner. They are not only diluents, but also, under the influence of 
hydrochloric acid, nutrients. Thus, in acute and debilitating diseases 
which furnish no, or little, hydrochloric acid in the gastric secretion, 
a small quantity of the latter, well diluted, must be provided for. 
This, my method of infant feeding, which is suited to the stomachs 
and purses of the rich and poor alike, is, however, not the only one 
proposed and found satisfactory. No single method, indeed, is the 
only one, nor does it suit every case. It is only an occasional chemist 



16 FEEDING OF SICK CHILDREN 

who expects the organic stomach to behave like a chemical reagent ; 
clinicians, however, admit exceptions to the working of their rules 
and regulations, though their conception were ever so correct and 
physiological. Still, the endeavors to improve the diet of the young, 
and thereby to remove the dangers of intestinal disorders and the 
sources of excessive mortality and invalidism, are going on. Nothing 
has been more successful in that direction, in spite of such dangers 
as will be mentioned below, than a rational practice of sterilization 
and pasteurization of cow's milk. Both are the logical development 
of the plan of treating milk by boiling which I have persistently 
advised these forty years at least, and detailed in my " Infant Diet," 
in Gerhardt's " Handbuch," in Buck's " Hygiene," in " Intestinal 
Diseases of Infancy and Childhood," * and in my clinical lectures 
delivered these more than forty years. There can hardly be a doubt 
that if raw milk could always be had unadulterated, fresh, and un- 
tainted, and as often as it was wanted, it would require no boiling. 
It would even contraindicate it, for high temperatures destroy not 
only some of the dangerous, but also those bacteria whose action is 
desirable for normal digestion. Besides, there are those who justly 
believe that boiling causes chemical changes. But such ideal milk 
can rarely be had so long as cows are tuberculous, or scarlet fever 
and diphtheria are met with in the houses and about the clothing and 
on the hands of the dairymen and women, and typhoid stools are mixed 
with the water which is used for washing utensils. 

Now, what is it that boiling can and will do? Besides expelling 
air, it destroys the germs of typhoid fever, Asiatic cholera, diphtheria, 
and tuberculosis, also the many bacteria which cause the change of 
milk-sugar into lactic acid and the rapid acidulation of milk with 
its bad effects on the secretion of the intestinal tract. Some varieties 
of proteus and most of bacterium coli are also rendered innocuous 
by boiling. Thus it prevents many cases of infant diarrhoea and 
vomiting, but not all of them, for the most dangerous bacteria are 
influenced neither by plain boiling nor by the common methods of 
sterilization. Besides, " diarrhoea" is but a symptom of many causes, 
and " cholera infantum" is a name for a condition occasioned by 



* Page 18. " After boiling, milk destined for the use of a baby during the 
day should be kept in clean bottles containing from three to six ounces, filled 
up to the cork, and the bottles then turned upside down in a cold place; such 
will keep longer than milk preserved in the usual way. Before being used it 
should be heated in a water-bath ; and by repeating this heating of the whole 
amount of the day's milk several times during the twenty-four hours, fer- 
mentation will be retarded and digestibility improved." 



GERMS IN F^CES. GERMS IN BREAST-MILK 17 

many. Indeed, Ebstein emphasizes the fact that babies at the breast 
are subject to cholera infantum, particularly in southern climates, 
also in public institutions. The influence of external temperature is 
a very important factor; its sudden changes produce intestinal dis- 
orders. Babies taken from a hot railroad car to the deck of a lake 
steamer, from a warm bed to a draughty room, or those that are kept 
outside their beds with wet diapers, may develop a catarrhal enteritis 
which disposes to worse forms of disease, for the morbid condition 
of the epithelium caused by such sudden changes is a proximate cause 
of disease because it opens the way to all sorts of infecting substances. 
Poisons in the food of cows, indigestible baby foods, — either indigesti- 
ble per se or through a morbid condition of the digestive organs, — pro- 
duce diarrhcea of many varieties. It need not even depend on ingested 
food, for, according to *W. Schild's careful investigations (Zeitsch. 
f. Hyg. u. Infect., vol. xix.), since confirmed, germs of diseases 
may be found in the intestine of the newly-born in from ten to seven- 
teen hours after birth (minimum four, maximum twenty) . The meco- 
nium of the newly-born, being free of germs, is supplied through the 
mouth with the bacterium coli, and through the anus with the bacillus 
fluorescens, subtilis, and proteus. Even adults are infected through 
the same inlet. Linen, the bath, the air, the blood, and perhaps more 
than anything else the hands of the nurse are sources of local inva- 
sion. In such cases what is the sterilization of artificial foods to 
accomplish? They are not reached by it. 

Not even the natural food, breast-milk, is free of germs possibly 
attended by dangers. M. Cohn and H. Neumann found germs in 
the healthy breast-milk, even after the mamma and nipples had been 
washed with alcohol and with solutions of corrosive sublimate. A. 
Palleske met with the staphylococcus pyogenes albus in one-half of all 
healthy women, F. Honigmann (Zeitsch. f. Hyg. u. Infect., vol. xiv.) 
in most of them, and H. Knochenstein (Inaug. Diss., 1893) in the 
mammae of eight puerperal and nursing women. He thinks they had 
emigrated from outside ; they proved innocuous. But who can doubt 
that if the epithelium of the milk-ducts had been abnormal there 
would have been a chance for mastitis, or if the staphylococcic milk 
had come in contact with a sore stomach or intestine there would 
have been an opportunity for gastritis or enteritis? Many more 
observers have come to the same conclusions. Several species of 
cocci, particularly staphylococcus pyogenes albus, are found in most 
(perhaps in all?) specimens of the milk of healthy women. In that 
of sick women many more bacteria may be met with; for instance, 
streptococcus albus, streptococcus pyogenes aureus (in mastitis by 

2 



18 FEEDING OF SICK CHILDREN 

Cohn and Neumann), coccus pneumoniae (in pneumonia of the mother 
by Foa and others ) . Puerperal women with fever had several bacteria 
in their milk (Escherich). Whether such milks are safe cannot yet 
be either asserted or denied. 

Boiling, or sterilization, is by no means a safe protection under 
all circumstances. Aerobic bacteria, the so-called hay or potato bacilli, 
have very resistant spores, which develop in time. They are found 
in cow-dung and in the dust of stables, of the soil and streets, and 
of hay; they render the milk strongly alkaline and bitter; they pep- 
tonize casein and liquefy it and make the milk still more bitter. They 
are very poisonous ; their pure culture gives young dogs a fatal diar- 
rhoea. It takes hours of sterilization to kill them ; in some instances 
it required five or six hours. Even the bacillus butyricus takes an 
hour and a half. But such a protracted sterilization, besides being 
far from certain in its effect, is a clumsy procedure and one not calcu- 
lated to benefit the milk. Thus, hay feeding is an absolute necessity, 
if cows are to give a milk fit to be taken by babies, for by a six weeks' 
drying the bacilli are destroyed. Besides, it is important to keep the 
stables scrupulously clean, to avoid dirt and dust, to employ peat 
instead of straw for bedding, to wash the udder and tie the tails 
before milking, to throw away the first milk, and to remove foreign 
material from the milk by filtering. Centrifuging for that process 
is not safe, for it may change the character of the milk. But no 
absolute security can be guaranteed. Indeed, there are exceptions 
to this universal efficacy. Heins found cholera bacilli in sterilized 
milk after four weeks, typhoid after four months, and according to Dr. 
Lydia Rabinowitsch {Deutsche med. Woch., 1900, p. 490), experi- 
ments made in the Institute for Infectious Diseases in Berlin appear 
to prove that occasionally tubercle bacilli are not killed by less than 
ioo° C. Organisms surrounded by fat seem to require more than the 
average heat to be destroyed ; in accordance with the findings of 
Ignard, which appear to prove that unsterilized butter would preserve 
cholera and tubercle bacilli much longer than unsterilized milk. If 
that be beyond doubt, butter and rich milk would retain their infecting 
qualities longer than average milk with a moderate percentage of 
fat. So there may be a danger in fat milk which does not exist in 
milk that contains less fat. 

Whatever I have here brought forward is certainly not to dis- 
parage the boiling of the milk; it is meant to prove the danger of 
relying on a single preventive when the causes of intestinal disorders 
are so many. It is true, however, that the large majority of the latter 
depend on causes which may be met by sterilization, but not by sterili- 



STERILIZATION AND PASTEURIZATION 19 

zation only ; also by pasteurization, — that is, heating the milk to 70 
C. = 158 F., and keeping it at that temperature for thirty minutes, 
— a procedure which destroys the same germs that are killed by a more 
elevated temperature without much change in the flavor and taste of 
the milk. 

One of the questions connected with the employment of sterilized 
or pasteurized milk is this: whether the milk to be used for a child 
ought to be prepared at home, or whether the supply may be procured 
from an establishment where large quantities of milk believed to 
become immutable for an indefinite period by sterilization are kept 
for sale. In regard to this problem, Fliigge plaintively expresses his 
regrets that " we have allowed ourselves to be guided by people 
who are neither hygienists nor physicians, but chemists, fanners, or 
apothecaries, and whose actions have been based on three false beliefs. 
Of these the first is that boiling for three-quarters of an hour destroys 
germs, the second that whatever bacteria remain undestroyed are 
innocuous, and the third that proliferating bacteria can always be 
recognized by symptoms of decomposition." Nothing is more erro- 
neous. Soxhlet himself, the German originator of sterilization, knew 
at an early period that the fermenting process is now and then but 
partially interrupted by boiling, that butyric acid may be found in 
place of lactic acid, that a strong evolution of gas may be caused after 
such boiling, and that such milk may give rise to flatulency. Aye, 
milk which happens to contain the resistant spores of bacteria be- 
comes a better breeding-ground for them by the very elimination of 
lactic acid, and the longer such sterilized milk is preserved and offered 
for sale the worse is its condition. It may be true that these condi- 
tions are not met with very frequently, but an occasional single 
death in a family caused by poisonous milk will be more than enough. 
Therefore, the daily home sterilization is by far preferable to the 
risky purchase from wholesale manufacturers who cannot guarantee 
because in the nature of things they cannot know the condition of 
their wares. 

Another alteration of a less dangerous character, but far from 
being desirable, is the separation of cream from sterilized milk which 
is preserved for sale. Renk (Arch. f. Hyg., vol. xvii.) found that it 
took place to a slight extent during the first weeks, but later to such 
a degree that 43.5 per cent, of all the cream contained in the milk was 
eliminated. 

According to A. Weber (Arb. axis d. kaiserl. Gesundheitsamt, 
vol. xvii., 1900, p. 108), the present wholesale procedures of sterilizing 
milk cannot furnish milk that is absolutely free from germs. The 



20 FEEDING OF SICK CHILDREN 

nearer the milk he investigated approached absolute sterilization the 
more readily could the gross chemical and physical changes occasioned 
by sterilizing be noticed. 

He found Fliigge's " poisonous peptonizing bacteria" three times 
in one hundred and fifty specimens of commercial sterilized milk. 
They were " hay bacilli," which cause a strong decomposition of 
albumin and copious development of hydrogen sulphide. It is par- 
ticularly this rapid putrefaction which proves dangerous to the nurs- 
ling. 

While in sterilized milk the anaerobic microbes are neither numer- 
ous nor important, according to the same author, the aerobic kinds 
are able to peptonize milk in from one to two days (some species 
in from five to seven), and to cause putrefaction and produce hydro- 
gen sulphide. Raw milk is indeed protected by its milk-sugar, which 
by being transformed into lactic acid destroys the effect of peptonizing 
bacteria ; in sterilized milk the latter are apt to predominate. 

Consequently, domestic daily sterilization (or pasteurization) is 
to be preferred to wholesale production, unless this be daily. That 
is why even Henri de Rothschild's advice is not unobjectionable. He 
attributes all the failures of sterilization to its erroneous methods 
only; he advises not to use the wholesale product when it is more 
than from eight to ten days old, and only in flasks of from fifty to 
one hundred and fifty cubic centimetres. He also prefers daily home 
sterilization of forty-five minutes each. Even in this, as we shall 
see, there are mistakes. 

The taste of milk begins to change at 75 C. (Duclaux), the 
milk albumin is altered at about from 65 ° to 70 , according to some 
at 6o° C. Dairymen ascertained that fact from their experience in 
cheesemaking. Jemma found that pepsin and hydrochloric acid 
digest milk sterilized at ioo° C. more slowly than raw milk. During 
sterilization 'lime salts are thrown out, phosphorus combinations are 
disintegrated, nitrogenous substances are liable to be decomposed into 
tyrosin, peptotoxin, and ammonium, lecithin is destroyed, fat changed 
both chemically and physically. During a long-continued sterilization 
casein and nucleon are likely to undergo marked changes, and the 
sugar has been found at the bottom as a brown deposit. That is 
mainly so when excessively high temperatures are employed, — for in- 
stance, no° C. by wholesale sterilizers (" surchauff age"), which cause 
the production of peptone by the action of chlorine on casein, or from 
ioo° to 105 ° C. in steam heat. But even these high temperatures do 
not accomplish actual and complete sterilization in all cases. Chemical 
toxins are not changed by them or even by greater heat, and spores 



ADVANTAGES OF LOW TEMPERATURES 21 

are very obstinate, such as those of bacterium subtile and tyrothrix, 
which resist the usual methods. 

But, after all, the destruction of microbes by heat is such a prog- 
ress over all previous methods of employing milk, provided it cannot 
be obtained fresh and fairly sterile, that its disadvantages are too 
apt to be overlooked. In some cases heat is insufficient in its effects, 
obstinate bacteria not being destroyed ; in other instances its excessive 
effect proves dangerous by destroying milk elements. While appre- 
ciating the latter danger, which is due to prolonged heating mostly, 
we should never forget, however, that the advantages of heating 
derived from the destruction of microbes, which are either directly 
pathogenous or indirectly so by increasing the virulence of sapro- 
phytes, are incalculable. But with every degree beyond pasteurization 
the disintegration of the milk becomes more marked; therefore it 
appears that no greater heat than from 65 ° to 68° C. should be em- 
ployed, though it may be found wiser to extend the process over a 
longer time. 

The lower the degree of heat which may be expected to destroy 
lactic or pathogenous microbes the more easily the integrity of milk 
is preserved. Now, Theobald Smith (Jour, ex per. Med., 1899, vol. 
iv., No. 2) found that in distilled water, in physiological solution 
of sodium chloride, in beef -broth, or in milk, zvhen heated to 6o° C. 
(140 F.), tubercle bacilli die mostly in from five to ten, all of them 
in from fifteen to twenty minutes. The membrane, however, which 
is formed on milk even at 60 ° C, keeps tubercle bacilli alive even after 
sixty minutes; that is why its formation should be prevented by 
stirring, or it should be removed. 

This low temperature preserves also the taste of milk and is at 
the border line only of the temperature that coagulates lactalbumin. 
The confirmation of these observations made by one of the most 
reliable experimenters will not be wanting; then nothing will be 
required except a cheap and handy apparatus to prevent milk from 
getting warmed beyond 6o° C, thus preserving its freshness and re- 
ducing or removing its dangers. 

Sterilization has been claimed to be no unmixed boon because of 
its changing the chemical constitution of milk. Still, opinions on that 
subject vary to a great extent, the occurrence of changes being both 
asserted and denied by apparently competent judges. But what I 
have said a hundred times is still true and borne out by facts, — viz., 
that no matter how beneficial boiling, or sterilization, or pasteurization 
may be, it cannot transform cow's milk into woman's milk, and that 
it is a mistake to believe that the former, by mere sterilization, is a 



22 FEEDING OF SICK CHILDREN 

full substitute for the latter. It is true that when we cannot have 
woman's milk we cannot do without cow's milk. There is no alleged 
substitute that can be had with equal facility or in sufficient quantity. 
But, after all, it is not woman's milk. Babies may not succumb by 
using it, and may but seldom appear to suffer from it ; indeed, they 
will mostly appear to thrive- on it ; but it is a makeshift and requires 
modifications. 

Ergo, cow's milk is not woman's milk. It is not identical with 
it. Sterilization does not change its character; it merely obviates 
such dangers as result from the presence of most pathogenic germs 
and from premature acidulation. The substitution of cow's milk or 
of sterilized cow's milk for woman's milk as the exclusive infant food 
is a mistake. Experience teaches that digestive disorders, such as 
constipation or diarrhoea, and constitutional derangements, such as 
rhachitis, are frequently produced by its persistent use, and it ap- 
pears to be more than an occasional (at least co-operative) cause of 
scurvy. 

Since the advisability of finely dividing and suspending the casein 
of cow's milk and of adding to the nutritiousness of the latter caused 
me always to teach the admixture of cereals to it, even in the very 
first days of infancy, the subject of infant feeding has never been 
lost sight of by medical men, scientists, and tradesmen. No subject 
has been treated more extensively, more eagerly, sometimes even 
more spitefully, than that of infant feeding. The philosopher's stone 
has not been so anxiously sought for nor so often found in medical 
journals, books, and societies as the correct infant food and the appro- 
priate treatment of cow's milk. After the finally faultless thing had 
been discovered very many times, it was not a surprise but a source 
of gratification to me to meet, in the Berl. klin. Woch., No. 10, 1895, 
an article of Heubner, who, after having contributed for years as 
much as any writer (if not more) to the literature of the subject, 
recommends the " utilization of flour in the intestines of young 
nurslings." Basing his remarks, first, on the researches of Schiffer, 
Korowin, and Zweifel (quoted in my early writings on that topic 
thirty years ago), who, by experimentally proving the digestibility 
of a certain amount of starch in the saliva (and pancreatic juice) of 
ypung infants,* justified my empirical findings of many previous 



* While it took Heubner more than twenty years to remember very 
accessible physiological experience, a celebrity of equal rank (Philip Biedert. 
Handbuch der Kinderkrankheiten, nth ed., 1894, p. 39) still appears to approve 
of the opinion that a nursling must have " no amylacea," because of their indi- 



DILUTION OF ARTIFICIAL FOODS 23 

years, and, secondly, on what he is pleased to call " Jacobi's practical 
experience," the Berlin physician recommends in intestinal diseases 
of the very young the simplest flours, mainly of rice and oats (which 
have a finer microscopical structure than wheat). He pointedly adds, 
" Very young infants do better on a dilution of milk with a thin rice 
decoction than with mere milk-sugar solution. Practical experience 
overrides theoretical conclusions." * There is but one point in which 
the famous teacher does not yet agree with me, for in his expositions 
we meet with the remark that he " cannot approve of the colossal 
dilution recommended by the authority of Jacobi." The " colossal 
dilution" alluded to is that of milk in four or five parts of oatmeal- 
or barley-water for the use of the newly-born. In regard to this 
dilution also I trust I shall yet see my illustrious colleague siding 
with me. The demands of pepsin digestion and of rapid growth and 
the necessity of restitution of losses experienced by elimination and 
excretions are just so many reasons for extra allowances of water 
in the diet of very young infants, who have to rely on the services 
of others. Older children know how to find it and how to serve 
themselves. In addition, it is certainly true that a large amount of 
water passing through the kidneys removes the inconveniences and 
dangers of the peculiar physiological process which takes place during 
the first three weeks of every life, — viz., uric acid infarction, — the 
results of which are gravel, renal calculus (by no means rare), and 
nephritis, which is frequent. Indeed, since the rather frequent adop- 
tion of my plan of supplying the very young with quantities of water, 
I hear less of renal complaints in them than I did dozens of years ago. 
Perhaps the tide is already beginning to turn in my direction. 
Norbert Auerbach, whose researches on the difficulty of destroying 
the hay bacillus and the bacillus butyricus are very meritorious, recom- 
mends larger percentages of water in infant feeding than the cus- 
tomary ones. His mixtures for the first and second months of life 
are three parts of water and one of milk; for the third and fourth, 
two and one; for the fifth and sixth, one and one; for the seventh 
and eighth, one and two. His figures are, therefore, not exactly like 
mine, but even they may appear heretic to my critic. In connection 
with this subject I am also pleased to state that Auerbach agrees 
with me on another subject. The sugar he adds to the milk food 

gestibility, before the protrusion of teeth. Still, he advises cereals for the dilu- 
tion of his cream mixture. Before long it will be a generally accepted axiom 
that cereals must be given to make teeth and tissues generally when milk food 
alone does not suffice for their development. 
* " Probiren geht iiber Studiren." 



24 FEEDING OF SICK CHILDREN 

of infants is not milk-sugar, but cane-sugar, of which he gives twenty 
grammes daily, and — also according to my old teaching — more during 
constipation. He undoubtedly prefers cane-sugar for the reasons 
which guided me in my recommendations, though it is true that milk- 
sugar is being partly stripped of its dangers in the same degree as 
boiling, sterilization, or pasteurization is carefully practised. 

Virtually, sterilization has been practised by me these more than 
forty years, and has been taught by me for thirty-five years; but 
actual sterilization, according to Soxhlet, was introduced in New 
York by A. Caille. Then manufacturing firms took it up as a matter 
of course. One of them was prevailed upon by me to execute a 
device of Dr. A. Seibert, who advised the determination of the amount 
of sterilized food and the graduation of the feeding-bottles according 
to the weight of the infant. In most cases this plan is good, for the 
condition of the child can mostly be measured by the increase of its 
weight. Only fat, clumsy, rhachitical children are exceptions ; in 
them the rapid increase of weight is a morbid condition rather than 
a symptom of healthy development. Besides, he improved his food 
by adding, in conformity with my practice, and sterilizing at the same 
time with the milk, either barley- or oatmeal-water. A recommenda- 
tion of his sterilizer is its cheapness, which makes it more accessible 
to the poor. Before being sterilized (pasteurized) milk ought to 
be filtered. Most cooks employ napkins for that purpose. Dr. Seibert 
recommends absorbent cotton. 

Both sterilization and pasteurization have conquered a fair stand- 
ing in the popular mind. Unless, however, there be a rational time 
limit, the practice may become dangerous ; the decomposition of the 
milk by oversterilization I have discussed before; scurvy and other 
ailments may be its results. In New York the writings and practical 
instruction of Dr. Rowland Godfrey Freeman have been of great 
advantage, particularly to its poor population. He insists upon pas- 
teurization as a sufficient method of safety. The apparatus devised 
by him is thoroughly appropriate. As the adviser of Mr. Nathan 
Strauss in his successful endeavors to supply thousands with a safe 
article of food, he has benefited the city and aided in setting an exam- 
ple which should and will be imitated. 

Pasteurization is also employed by Rotch. In a paper read before 
the American Pediatric Society at Boston, May 4, 1892,* he presented 

* The Value of Milk-Laboratories for the Advancement of our Knowl- 
edge of Artificial Feeding, by T. M. Rotch, Archives of Pediatrics, February, 
1893. Also Pediatrics : The Hygiene and Medical Treatment of Children, 
Philadelphia, 1896, 2d ed., 1901. 



MODIFICATION OF MILK BY ROTCH 25 

for the first time, among others, the following statements, which I 
gladly repeat, as I know his teachings to have done a great deal 
of good. Indeed, I was so much impressed by them that I en- 
couraged the gentleman who had conducted a milk-laboratory on 
Dr. Rotch's plan in Boston to establish a similar institution in New 
York. 

According to Dr. Rotch, " What the profession needs is the knowl- 
edge that they may have milk-laboratories where the materials are 
clean, sterile, and exact in their percentages. Slight changes in the 
three elements of milk of which we have the most accurate knowledge 
—namely, fat, sugar, and albuminoids — are of real practical value in 
managing the digestion and nutrition of the infant (normal percentage 
of fat, from 2.02 to 4.37; of milk-sugar, from 5.70 to 7.10; of albu- 
minoids, from 1.08 to 3.07 ; of mineral matter, from 0.12 to 0.20) . The 
digestive capabilities of infants differ just as do those of adults, and 
nature therefore provides a variety of good breast-milks adapted to the 
individual idiosyncrasy of the special infant. With this fact impressed 
upon us, we can well see that in artificial feeding no routine mixture 
will in all cases prove successful." 

All this proves also that nature allows a great deal of latitude, 
for the milk of a woman is changing, sometimes quite rapidly, and 
still the baby continues to thrive. It also proves that an attempt at 
regulating the percentages of milk according to invariable rules, while 
circumstances of surroundings and individual health — perceptibly 
changed or not — may differ, is liable to be very deceptive. Altogether, 
no iron-clad rule holds good for a living body in which organic assimi- 
lation is not regulated by the fixed laws of crystallization. This is, 
indeed, proved by nothing better than by the variability of the con- 
stituents of good milk. According to the very figures presented by 
Dr. Rotch himself, fat may vary from 2.2 to 4.37, albuminoids from 
1.08 to 3.27, and still the milks exhibiting these wide differences are 
" normal." 

In regard to the percentages of fat in cow's and in woman's milk, 
the results of chemical analysis have lately changed in favor of the 
latter. But the general principles in regard to fat feeding — its effect 
on digestion, and the normal occurrence of fat in the healthy faeces 
of an infant fed on normal nourishment (breast-milk) — are not 
thereby altered. 

Neither mathematics nor chemistry alone directs the organic econ- 
omy. If that were so, the chemist Soxhlet, otherwise so deserving 
and justly famous, would be justified in the advice he coolly gives 
the physician to add milk-sugar when there is no fat in the food, and 



26 FEEDING OF SICK CHILDREN 

thereby to obtain the necessary amount of carbohydrates. Fortunately, 
organic chemistry is not identical with physiology. 

Dr. Rotch continues, " We are in need of a means by which we 
can prescribe exactly according to the idiosyncrasy of the digestion 
we are dealing with. 

" A separator with many thousands of revolutions in a minute 
separates from the milk foreign material and divides it up into a 
cream of a stable percentage and separated milk. The milk-sugar 
and the albuminoids, also the mineral matter of this milk, are fairly 
well known, and thus the laboratory worker is enabled to put up any 
prescription, which, for a healthy baby of four months, would read : 
fat, 4 parts; milk-sugar, 7 parts; albuminoids, 1.50 parts. Put up 
eight tubes, each four ounces, with lime-water ten per cent. Pas- 
teurize (75 C. = 167 F.) for twenty minutes. In this mixture the 
lime-water is just sufficient to slightly alkalize the cow's milk.* In 
this way the food of the child can be modified according to age and 
to changed conditions of health." 

In a case of duodenal jaundice in a girl of six years, the doctor 
prescribed fat, 0.5 part ; milk-sugar, parts ; albuminoids, 4 parts. 
Give four ounces every two hours. Send twelve tubes, each four 
ounces, lime-water ten per cent. In a case of summer diarrhcea in a 



* Cow's milk is either alkaline or neutral or acid. The constant recom- 
mendation of ten per cent, of lime-water for the purpose of alkalization is. 
therefore, far from exact and strictly scientific. Besides, how much alkaliza- 
tion is effected by three drachms of lime-water? They contain exactly, Gl- 
are presumed to contain, one-quarter of a grain of lime. 

Lime-water (Jiquor calcis) is a saturated aqueous solution of calcium 
hydrate whose percentage varies with its temperature. At 59 F. it contains 
somewhat over 0.17 per cent., in rising temperature less, at the boiling point 
one part of lime in thirteen hundred of water. It redissolves as the liquid 
cools. If the food containing lime-water be given at a temperature of 8o° 
or 90 F., part of the lime is thrown out. Lime-water warmed loses most of its 
alkaline reaction ; it is markedly alkaline when cold, only faintly so when 
boiled. An experiment made with good milk from the household supply gave 
the following results. Reaction acid, also on boiling. One-twentieth part of 
lime-water added to it changed the reaction but slightly ; it remained acid. 
The mixture being boiled, reaction remained the same. When again cooled 
and shaken up it was still acid, but slightly less so than before the dilution of 
the milk with lime-water. 

The addition of sodium bicarbonate to milk which is to be kept from 
souring, a procedure which is (besides lime-water) recommended by Dr. Holt 
also, may become a grave mistake. The very bacilli which, with their spores. 
resist boiling to an unusual degree, thrive best in a milk that is made thor- 
oughly alkaline. 



RESULTS OF MODIFICATION OF MILK 27 

girl of four months, fat, 2 parts ; milk-sugar, 5 parts ; albuminoids, 
1 part. Send twenty tubes, each one ounce and one drachm. At time 
of each feeding add lime-water, three drachms. Sterilize at 212 F. 

One of the beliefs guiding the author of this method is as follows : 
" The constituents of the nutriment which nature has provided for 
the offspring of all animals and human beings that suckle their young 
are* essentially animal, and not vegetable. Human beings in the first 
twelve months of life are carnivora. An animal food entirely and 
always free from any vegetable constituents has been proved to be 
the nutriment on which the greatest number of human beings live and 
the least number die." 

Those who have followed my teachings at any time during the 
last third of a century know that I take some exception to this broad 
statement. Saliva and pancreatic juice are good for something better 
than idle elimination, and " nature'' prepared the animal young from 
the first moment for more than mere pepsin digestion. The proof 
Dr. Rotch refers to is his experience only. Mine has taught me some- 
what differently from the axiomatic positiveness of his assertion. 
But be it far from me not to present Dr. Rotch's case in full. His 
standing and merits are such as to give him a hearing wherever and 
whatever he discusses. His rules, which, moreover, may be modified 
by my method at any time, are thoroughly good; they are scientific, 
exact, and well thought out. Moreover, they have been proved to 
be practicable. No matter whether it is the careful handling of a 
cautiously prepared milk, the methodical composition according to 
percentages, or the faithful pasteurization, or all of them, the results 
are good. I know of a number of babies who in health and disease 
have done well on the protracted use of the laboratory milk. Only 
one observation struck me in many cases. The formation of the 
muscles, and particularly of the bones, appeared to be slow; the 
teeth came a number of weeks or even months too late; the cranial 
bones turned slightly soft in not a few instances. In many such cases 
I had to add animal broths or juice before the usual time; in two, 
when I tried phosphorus (elixir phosphori), it was rejected; in all 
others it was well borne and useful. But, taken all in all, the method 
appears to be sound and successful, so far as it can be with cow's 
milk and the casein of cow's milk. It is to be deplored that for the 
present it is a method only accessible to the rich ; it required a special 
benevolent fund to supply one hundred and twenty-five Boston poor 
children with the same food; mine has the advantage of being one 
for the people, both rich and poor. If, or as long as, the circulars 
of the laboratory keep free of pretentious exaggerations, — there was 



28 FEEDING OF SICK CHILDREN 

a time when they took that turn, — the profession will do well to rely 
on it, or its like, as one of the means of furnishing the baby a food 
deprived of dangers and in most cases sufficient. When it is found 
insufficient as regards tissue-building, cereals may always be furnished 
in the same mixture. The empirical knowledge of their beneficial 
effects with which we have been furnished for more than a generation 
has lately again been tested experimentally by Springer, of Paris, who 
improves the development of bone by a decoction of mixed cereals 
boiled for hours in succession. This long duration of the boiling 
process is, however, not demanded. 

Rotch's " modified milk" feeding has become frequent in our large 
cities, — Boston originally, New York, Philadelphia, Chicago. It is 
expected that a baby has a prescription given by the doctor, and that 
the daily portions are prepared in and sent from the laboratory. But 
the most frequent procedure is at present this : that people will apply 
at the laboratory and the barmaid in charge will prescribe according 
to the printed schedules of proportions which are said to correspond 
with certain ages, — a very unscientific application of a method which 
was meant to be the very essence of scientific accuracy adapted to 
the individual case. One reason why Dr. Rotch insists upon the labo- 
ratory furnishing the separate meals is that he does not trust mothers 
in regard to accuracy and to cleanliness (Festschrift in honor of Dr. 
Jacobi, New York, 1900, p. 318). I must admit I am of a different 
opinion. I know of flies and other foreign substances in the " modi- 
fied milk" bottles sent from some " laboratory." .That they were also 
sterilized does not help the case ; indeed, the larger the number of 
strangers and paid employees who are to do your work the greater 
is the possibility of mistakes. 

The method is rather expensive and always must be. The annual 
income of many a workingman would have to be spent on the baby's 
feeding. The objections raised to this and the urgent necessity of 
finding substitutes for the population at large, rich and poor alike, 
made Rotch say {Boston Med. and Surg. Journal, September, 1895, p. 
293) that " the advance in infant feeding was very much impeded 
by the cry in New York a few years ago for cheap food for the poor." 

There can be no doubt that the end aimed at by Dr. Rotch is 
partly obtained by securing a reliable and approximately fresh milk 
and by sterilizing it in small portions. In that he has performed, 
with Coit and others, most valuable educational and missionary work. 
That, however, the six thousand eight hundred revolutions a minute 
should leave the milk intact, that after the mixture of its " disjecta 
membra" we should again have milk, is not very probable. Lunin 



GARTNER. BIEDERT. MEIGS 29 

(Dis. Dorpat, 1880) fed mice on milk and they lived, but they died 
when the constituent parts of milk, after having been severed, were 
recompounded. I know, however, of no experience of the same 
nature. 

The " f at milk" (" Fettmilch") of Gartner is also obtained by 
centrifuging and sterilizing. According to Escherich's analysis of 
woman's and of cow's milk, this preparation is to contain casein 1.76, 
fat 3, and sugar 2.4 per cent. It is preserved in tin cans, which are 
favorable to occasional decomposition. Bad odor, discoloration, and 
fat swimming on top are frequent occurrences. It is expected to be 
given indefinitely, and no consideration is paid to the fact that woman's 
milk (not to speak of colostrum) contains more albumin and salts 
and less fat in the first few months, but less albumin and salts and more 
fat later. 

Biedert prepares a cream mixture which contains one per cent, 
of casein, two of fat, and four of sugar. It is to be mixed with milk 
in different proportions. One of the reasons urged by him for the 
addition of cream is the necessity of greater dilution (accomplished 
by my cereal decoctions) of the cow casein, the difficult digestion of 
which he takes for granted. 

In his " Kinderernahrung," 2d ed., pp. 152, 170, he recommends 
to feed a baby during the first few months as follows : every kilo- 
gramme (two pounds) of the baby's weight is furnished two hun- 
dred grammes (six and a half ounces) of food which contains fifty 
of milk, one hundred of oatmeal- water, and eight of sugar. Heubner 
(" Sauglingsernahrung und Sauglingsspitaler," 1897, p. 13) mixes 
one part of milk with one of a flour decoction (one teaspoonful to 
one-half pint) which contains 12.3 per cent, of milk-sugar. Of this 
mixture he gives six hundred grammes daily up to the fourth week, 
seven hundred and fifty to the seventh, and nine hundred after the 
eighth, in from eight to six meals. 

The mixture of Dr. Meigs is well thought of by many physicians, 
In his own words, " There must be obtained a quart of good fresh 
milk, not too rich and not poor ; average milk is best ; this is 
placed in a high pitcher or other vessel and is allowed to stand in 
a cool place for three hours. The upper half or pint is then poured 
off, care being taken not to shake the vessel, and this upper pint of 
weak cream is to be kept for the use of the infant. 

" There must also be made a solution of milk-sugar of the pro- 
portion of eighteen drachms to the pint of water. It ought to be kept 
in a fairly cool place ; if it be sour it must not be used. 

" Three tablespoonfuls of each, the weak cream and the sugar- 



3o 



FEEDING OF SICK CHILDREN 



water, are then mixed with two tablespoonfuls of lime-water. They 
are then warmed for use in the feeding-bottle. 

" In the great majority of instances where it has been fairly tried, 
this food has proved very successful" (Arthur V. Meigs, " Feeding in 
Early Infancy," 1896, p. 7). 

This food of Meigs seems to be too easily influenced by irregu- 
larities and by accidents happening to what he calls cream during 
its formation, and to the milk-sugar solution, to be proof against fre- 
quent mistakes. Fortunately, however, digestion and assimilation 
are not regulated by mathematics. 

Dr. N. B. Coit, who believes that cow's milk when properly pre- 
pared furnishes the sufficient diet of an infant and supplies all its needs 
for robust health, gives the following rules for modified milk for infant 
feeding, made with one quart of bottled cow's milk : " First six 
months, the top milk, cream one-half pint, boiled water one pint, 
milk-sugar seven hundred grains; from six to nine months, the top 
milk, cream one pint, boiled water one pint, milk-sugar nine hundred 
grains ; from nine months to one year, the top milk, cream one and 
one-half pints, boiled water one-half pint, white sugar three teaspoon- 
fuls." 

From the very first month of life a distinct diastatic effect is pro- 
duced by the oral secretion ; it increases with every month. Even 
infusions of the parotids, prepared at different times after death, pro- 
duce the same effect. Infusions, however, of the pancreas taken from 
the bodies of infants who have lived three weeks produce no such 
changes. The diastatic power of the pancreas begins with the fourth 
week only, and remains feeble up to the end of the first year. Kriiger 
(1891) found in the fcetus of seven months a sugar-forming ferment 
which increases towards the normal end of intra-uterine life, is still 
small in quantity at birth, but grows so rapidly that it is as active 
about the eleventh month of life as it is in the adult. 

Zweifel experimented with infusions of different glands. That 
of the submaxillary glands of an infant did not transform starch 
into sugar, even after the lapse of a whole hour. The effect of an 
infusion of the parotid of a baby seven days old was distinct after 
four minutes ; however, that of the parotid of a baby which had died 
at the age of eighteen days, of gastro-enteritis, did not act until the 
lapse of three-quarters of an hour. Nor was a diastatic result obtained 
by a similar infusion made of the parotids of a baby prematurely born, 
and one who died of diarrhoea and debility. 

It is a remarkable fact that different varieties of starch are not 
changed by saliva into grape-sugar in the same length of time. In 



ACTION OF SALIVA AND HYDROCHLORIC ACID 31 

reference to the time required, however, there is no uniformity of 
opinion. Solera found that the transformation of the starch of the 
potato was the most rapid. Next came that of Indian corn, next 
wheat, and the transformation of the starch of rice was the slowest. 
According to Malay, raw starch changes slowly, boiled starch quickly. 
In his experiments, that of the potato required from two to four 
hours ; that of wheat from one-half to one hour ; of barley from ten 
to fifteen minutes ; of oats from five to seven minutes ; of rye from 
three to six minutes.* 

It is important to know that the effect produced by saliva per- 
sists in the stomach for a period of from one-half to two hours. But 
it ceases altogether, and starch will no longer be changed into grape- 
sugar, inside the stomach, as soon as the secretion of hydrochloric 
acid has begun in the digestive process. This is a very important 
fact, because it shows that the farinaceous food of the infant or child, 
though it be not masticated, and pass the mouth very rapidly, is in 
the stomach still under the influence of the saliva. 

Hydrochloric acid is not secreted at once. The first acids in the 
stomach while digestion is going on are organic, mostly lactic. This 
is found to be contained in that organ when gastric juice is removed 
from it in the first period of digestion. Thus in a gastrostomized 
boy Uffelmann found under normal circumstances, and in the absence 
of fever, during the first half-hour, lactic acid only ; afterwards hydro- 
chloric acid.f The latter is not met with during fevers of any kind, 



* When saliva is found insufficient at any age, medicinal aids are welcome. 
Taka-diastase has been recommended for the purpose of digesting starch. 
Friedenwald (N. Y. Med. Journal, May 29, 1897) is very enthusiastic in its 
praise. " It is employed in hyperacidity. It converts one hundred times its 
weight of starch in ten minutes, and thereby replaces saliva. It continues its 
action in the stomach, stimulates gastric secretion, and promotes the motor 
function of the stomach, and thereby the digestion of the proteids." 

f This agrees with what Ewald and Boas published as the result of their 
experiments. But they claim to have found hydrochloric acid only when 
a decoction of starch alone was introduced into the stomach. Still later Th. 
Rosenheim (Centralbl. f. d. med. Wiss., November 12, 1887) reports as fol- 
lows, after the ingestion of fifty grammes of bunn and one hundred and fifty 
of water. Free hydrochloric acid makes its appearance in the healthy stomach 
very early : 0.3 per mille after fifteen minutes, 1.0 per mille after thirty min- 
utes. This quantity or more is found until the elimination of chyme has been 
completed. From beginning to end there is lactic acid to a uniform amount, 
— viz., 0.3 per mille. In carcinoma there was but 0.1 per mille of hydrochloric 
acid, in hyperacidity 1.0 per mille. In every case and in every period of 
digestion there was lactic acid. There was less hydrochloric acid (but 0.2 



32 FEEDING OF SICK CHILDREN 

provided the temperature is high, nor during a severe gastric catarrh 
(and also in dilatation of the stomach resulting from congenital or 
other constriction of the pylorus). In these conditions farinacea 
(amylacea) are taken to advantage, principally because the diastatic 
effect of saliva is not disturbed. 

Some of the main points to be remembered from the foregoing are 
these : 

There is diminution or absence of saliva from the parotid in the 
very young while suffering from diarrhoea and debility. It is never 
copious. Thus the very young when well ought to have but little 
starchy food, and when sick still less, particularly as the pancreas 
cannot be relied on for diastatic action in the first weeks. 

Whatever saliva, however, has been secreted and is swallowed, 
continues its action in the stomach as long as there is no hydrochloric 
acid in it. This in the healthy is secreted only after half an hour 
or later; in the feverish and catarrhal stomach very much later or 
not at all. Thus what saliva is present displays its diastatic action 
continually. Therefore the food craved for and digested by children, 
also by infants to a great extent, is, besides milk, farinaceous. Animal 
food which requires hydrochloric acid is not wanted until later, nor 
is it readily digested in the stomach of the very young. 

In anaemia, convalescence, particularly in fevers, the functions of 
the stomach are impaired. In them both pepsin and hydrochloric acid 
are not secreted at all, or in very small amounts. In these cases fair 
quantities of water are required to start the secretion. 

Practitioners and authors who had convinced themselves of the ill 
success often attending the use of milk, or watered milk, commenced 
at an early period to mix it with MEAT-soups, meat-tea, or egg. 
Bretonneau reported, as early as 1818, that " tabes mesenterica" dis- 
appeared, in the hospital of Tours, from among the children fed on 
beef-soup and milk. This mixture Vauquelin declared, among all 
preparations, to come nearest to mother's milk. The administration 
of some beef-soup, well made, a cupful every day (mutton-broth when 
there is a tendency to diarrhoea), is advisable before the end of the 
first year. Long before this period, indeed at any time during infancy, 
it is indicated in cases of early rhachitis, though there be but few 

per mille after an hour) and a fair amount of lactic acid when carbohydrates 
only were taken, no matter whether saliva was admitted to or excluded from 
the stomach. 

These data are here added for the purpose of showing that the difficulties 
of arriving at absolute facts are exceedingly great. Still, the results of the 
three observers do not differ too much from the accepted doctrine. 



BEEF-TEA. BROTHS. PEPTONES 33 

symptoms such as rhachitical constipation, undue adiposity, or re- 
tarded teething. 

Beef-tea, well made, in a bottle swimming in the water-bath, is 
still believed by some to be the model food. That it is not so rich 
in soluble albuminoids as was believed ought to be generally under- 
stood by this time. What, however, it does contain in large quan- 
tities is salts. Thus it is a dangerous article in summer diarrhoea, 
and must never be administered by itself. When given at all, it 
ought to be in combination with farinacea or raw egg albumin (which 
in this mixture requires very little salt, if any). 

So far as albuminoids are concerned, beef-broth is about as nutri- 
tious as whey, and no more. But on account of the extractive sub- 
stances of beef, kreatin, and kreatinin, it is more stimulating. The 
temperature of the body is not raised by it. In gastric irritation, 
gastritis, and acute dysentery it ought not to be given. Veal-broth 
is liable to increase diarrhoea, mutton-broth constipation, and the 
latter is therefore preferable in cases of diarrhoea. A broth of beef, 
which contains from 1.5 to two per cent, of albumin, is made by 
mixing one part of beef and six of water with a little sodium chlo- 
ride and allowing it to stand from ten to twelve hours. Then it 
is slowly boiled and the whole mass pressed out. Still better is a 
modification of Liebig's beef-tea, which is obtained by adding one 
half-pint of water, with six or seven drops of dilute muriatic acid, 
to a quarter or one-half pound of finely cut lean beef, stirring it occa- 
sionally during two hours, and boiling a few minutes. Beef-juice 
obtained by pressing out beef after slightly broiling it contains from 
six to seven per cent, of albumin. It is only slightly acid, and spoils 
quickly. 

The peptonized beef preparations are available both internally and 
for rectal alimentation. They may be mixed with hot water or hot 
broth ; a few teaspoonfuls and upward are valuable additions to the 
daily food. Those who object to some of them because of their strong 
aromatic taste and color will still relish them when quite cold. Still, 
the administration of peptones should be controlled by a careful con- 
sideration of the condition of the digestive organs. The last product 
of gastric digestion is albumose ; the formation of peptone is not 
completed until the diastatic action of the pancreas, and perhaps also 
of some intestinal bacteria, has reached the chyme. It was taken 
for granted that neither albumose nor peptone could be formed with- 
out the presence of hydrochloric acid. In part this is a mistake, for 
dogs deprived of their stomachs, and men with no such secretion, 
are known to prepare them. Still, peptones have been given for the 

3 



34 FEEDING OF SICK CHILDREN 

purpose of supplying what the stomach could not, or was supposed 
not to be able to, furnish. They have a bitter taste, are not always 
well borne, even in the rectum, and may cause vomiting or purging. 
A teaspoonful of most of the peptone preparations holds from three 
to four grammes (two to three scruples) of albumin, which is a fair 
addition to the nutriment of a patient whose condition requires much, 
and very digestible, food. Still, sight should not be lost of the con- 
dition of the digestive mucous membrane. In conditions of fever, con- 
gestion, catarrh, etc., absorption is very slow ; much peptone is not 
absorbed, dyspeptones are formed, and a severe form of autoinfection 
may be the result. 

Scraped beef, raw, has been highly recommended in the chronic 
stage of, and convalescence from, exhausting gastro-enteric catarrh 
these forty years. It is very digestible and, but for the danger of 
causing taenia mediocanellata, a valuable addition to our means of 
restoring health. White meats contain less fat, haemoglobin, and 
extractive material than beef. Sweetbread (thymus), 22 per cent, 
albumin, 6 gelatin, but 0.4 fat, 1.6 salts, and 70 water. 

Meat thoroughly dried in the water-bath and finely powdered, 
also hard egg albumin in the same condition, are easily taken in milk ; 
they are excellent additions to a patient's diet at a somewhat advanced 
age (at and after three or four years). 

Egg has been utilized as an admixture to milk, or as its substi- 
tute, in a great many ways. Both the yolk and the albumin have 
been so employed. The white of an Qgg, with a little salt and six 
ounces of water or barley-water, well beaten and shaken, is a good 
mixture, which can take the place of infant food only temporarily, 
but is an invaluable makeshift in severe intestinal catarrh, or a per- 
manent nutriment in the same, when added to other food. 

Falkland skims milk and transforms it by means of pepsin. The 
process does not recommend itself to general use on account of its 
circumstantiality. Roberts heats milk to nearly the boiling point, and 
treats it with liquor pancreatis and sodium bicarbonate. Fair- 
child's method of peptonizing milk is generally understood all over 
the country and is widely appreciated. J. Rudisch's method of im- 
proving cow's milk for the use of children and adults, sick and well, 
particularly those who suffer from gastric catarrh and do not digest 
milk in its usual composition, consists in mixing twenty-five minims 
(half a teaspoonful) of dilute hydrochloric acid with a pint of water. 
Then a quart of milk is added. When this mixture is boiled but a 
few moments it keeps well and is quite palatable and highly digest- 
ible. It does not coagulate unless there be too much acidity in it. 



ARTIFICIAL NUTRIMENTS. ALCOHOL 35 

Somatose is one of the artificial preparations which deserves 
some credit, first, because of the absence of such nucleins as irritate 
the kidneys ; second, because it is a genuine albumose, a teaspoonful 
of which is claimed to contain as much albumin as is held in half an 
egg or three tablespoonfuls of milk. Thus, a number of teaspoonfuls, 
well diluted in water or in broth, or now and then in milk, may be 
given daily in cases of anaemia, or slow convalescence, or in sickness. 
To recommend it, however, as a regular food is " trade ;" to add it to 
cow's milk so as to make it " resemble human milk" (Rieth) is sheer 
nonsense. 

G. Klemperer, who discussed the artificial nutriments of the trade 
(Berliner klin. Woch., 1897, No. 26), took exception to every one 
because of their uselessness in " almost" every case. He correctly 
stated that the products of the trade are expensive, are mostly inferior 
to their promises and claims, and under ordinary circumstances should 
not be substituted for the direct products of nature. That is exactly 
the position I have always taken in regard to artificial foods ; but the 
practitioner, who deals both with commonplace and with exceptional 
cases, is glad now and then to fall back on some preparation which, 
while not requiring all of the normal process of digestion, may save 
life in a given case. There is no food which suits every stomach 
or every case in the well or in the sick, and the greater the facility 
of a wholesome change the better. That is why, now and then, the 
artificial farinaceous foods, in which amylum is more or less trans- 
formed into dextrin, are filling a gap in the rare cases in which milk, 
though ever so well prepared, or the cereals, like oatmeal or barley, 
are not tolerated. Of the artificial foods extract of malt, which, with 
its albuminoids, fifty-three per cent, of sugar, and fifteen of dextrin, 
is so nutritious that a tablespoonful is the equivalent of an egg, may 
be very serviceable. The percentage of sugar it contains is very 
nutritious ; in the same way the effect of sugar (cane- and even milk-), 
also of honey, ought to be utilized oftener than seems to be usual. 
The carbohydrates, generally, are the main food for the feeble 
and the feverish. Even the well will get along, but for a time 
only, with less albumin than was claimed by Liebig and by Voit, 
provided they are supplied with non-nitrogenous food. Under 
these conditions Hirschfeld limits the quantity of albumin demanded 
by an adult to thirty or forty grammes (one or one and a half 
ounces). 

Alcohol has conquered its place among the medicinal foods in 
the diseases of infancy and childhood. Very little, if any, is required 
in catarrhal, or the first stages of inflammatory, diseases. It is contra- 



36 FEEDING OF SICK CHILDREN 

indicated in the usual forms of meningitis, acute cardiac ailments, 
acute gastro-enteritis, peritonitis, and dysentery. It finds its appli- 
cation in depressed strength and vitality and in collapse; thus, in 
the rules for the management of infants during the hottest (the very 
hot only) days of summer, distributed during several decades by the 
Health Department of the city of New York, I recommended the 
administration of a teaspoonful of whiskey daily. Nobody appeared 
to find fault with me except some pulpits. It is also required in 
chronic diseases and slow convalescence. 

Its action is stimulant, nutritive, antipyretic, and antiseptic. It is 
decomposed into carbonic acid and water, and thus may save the waste 
of material parts of the body. When its odor is perceptible in the 
breath of the patient, it ought to be stopped or diminished. That 
is very liable to occur, for instance, in pneumonia, in the first stage 
of which alcohol is but rarely indicated or tolerated. When given in 
sufficient quantities, it reduces the temperature ; the amount required 
for that purpose is, according to Binz, forty grammes, corresponding 
to about three ounces of brandy or whiskey. Its most beneficial 
action is exhibited in sepsis of all forms, mainly also in the septic 
varieties of erysipelas, no matter whether there are brain symptoms 
or not, and of diphtheria. Here it is almost impossible to give too 
much. The doses must be watched so as to be sufficiently large. 
Whoever is not afraid to give, in diphtheria, six ounces of whiskey 
daily to a child when one or two fail, or ten or twelve when six fail, 
will soon convince himself of its power for good. It must never be 
given in concentration ; the gastric mucous membrane tolerates no 
pure brandy or whiskey for any length of time ; they must be diluted 
with either water or milk properly prepared. Wines, brandies, and 
whiskeys are not equivalent. In our country the latter is obtained 
pure with greater facility and at less expense, and besides has, for 
many, a less disagreeable taste than either of the others, which are 
often adulterated. The ether contained in wine militates against any 
antifebrile effect which may be expected from it ; the fusel oil, also 
the furfurol (or pyromucic aldehyde), and the salicylic aldehyde, 
which is used in the manufacture of bitters, and the artificial bouquets, 
with which brandies are too frequently adulterated, act rather as 
paralyzing than as stimulating agents. 

Alcohol is having a hard time between temperance women and 
sensational medical writers. We are told again and again in medical 
journals that when alcohol is taken in big doses a long time with 
no indications, the poor-house, convulsions, epilepsy, chorea, and crime 
are the inevitable results for the imbiber and his offspring, and for 



ALCOHOL. DYSPEPSIA 



37 



these reasons it must not be used in medical practice. We are often 
told that large doses are required to have its antifebrile effect, — the 
same thing Binz taught us three dozen years ago ; also that its stimu- 
lant effect, in small doses, depends on paralysis of inhibition only, — an 
explanation which does not detract from its value; that its stimulant 
effect is indeed imaginary only, for though it undergo combustion, 
some assert it does not prevent the disintegration of albumin in the 
tissues, and others that it does not diminish but rather increases the 
elimination of nitrogen. It is mainly Kassowitz who appears to have 
a personal grievance against alcohol (as also against diphtheria anti- 
toxin), and to make his point is not afraid to strain the truth to the 
utmost, and beyond. When he holds up my recommendation of 
whiskey in diphtheria to the horror of mankind, he adds, " Still, 
the same author advises to give healthy nurslings during the sum- 
mer daily a coffeespoonful of whiskey." This statement is a mistake, 
if nothing very much worse. What Kassowitz may have read is as 
follows : " in hot weather, but in the hottest weather only." 

Cushney * sums up his opinions by saying that alcohol deserves a 
place in therapeutics as a narcotic, and to a less extent as a stomachic, 
and in certain conditions as a food. Let him add, that it fills a place 
as a stimulant in septic (and other) diseases which cannot be replaced 
by any other, and that great clinicians like Curschmann or Jiirgensen 
use it as such, and he will be still more correct. 

Dyspepsia is one of the functional disorders of the stomach, and 
depends sometimes upon slight changes in the gastric mucous mem- 
brane only. It consists in partial or complete loss of appetite, with 
more or less impaired digestion. In regard to this, however, in every 
individual case, it is good not to rely too implicitly upon the reports 
of mothers or nurses. Older children will complain of precordial 
heaviness. They will suffer, as do infants also, from eructations, 
which, when they result from swallowing air, are absolutely odor- 
less, but when they consist of actual gastric gases, have a very faint 
odor. A sensation of oppression and frontal pain is complained of 
by older children ; the younger ones are apt to vomit. 

The causes of dyspepsia must be sought for either in anatomical 
changes in the organ (beyond the normal development of the intes- 
tinal glands, in contradistinction to the lymph apparatus which lags 
behind), which can rarely be proved, or (more frequently) in quan- 
titative or qualitative changes in the secretion ; or in a changed ner- 
vous influence, as, for instance, in fever ; or in an abnormal condition 

* Boston Med. and Surg. Jour., July 10, 1902. 



38 FEEDING OF SICK CHILDREN 

of the food, which is the most frequent cause, and the presence and 
first effect of pathogenous microbes. 

The treatment of this disorder consists chiefly in abstinence or 
in the use of the greatest care in the preparation of meals. Even 
mother's milk may have to be dispensed with and ice-water or small 
pieces of ice given instead. At all events, the casein must be greatly 
diminished. Milk requires boiling, peptonizing, or treating with 
muriatic acid according to the method I have detailed before. In 
every case the admixture of farinaceous decoctions and a little salt 
improves the digestibility of milk, though prepared as described. In 
many the latter alone, with or without a meat-broth, will be the only 
food which is tolerated. The gastric secretion of infants who have 
been fed artificially is liable to be hyperacid; then alkalies should 
be given at once. The addition of a few grains of sodium bicar- 
bonate (baking-powder) to the food may suffice. A few grains of 
an alkali (magnesia, sodium, calcium, according to the indications 
explained elsewhere), given a few minutes before every meal, act 
more surely. There may be the indication for bismuth, or for resorcin 
in small doses (i to 200 water), one-half to one teaspoonful every 
two or three hours, or for irrigation of the stomach mostly with a 
saline solution (6 to 1000), or for the administration of orexin tan- 
nate, which appears to increase the secretion of hydrochloric acid 
and the function of the muscles of the stomach. 

Vomiting has been mentioned among the symptoms which accom- 
pany dyspepsia. In the infant, however, it is almost a normal occur- 
rence. The infantile stomach is vertical and more or less cylindrical, 
and the fundus but little developed. Thus, whenever there is a ten- 
dency to empty the stomach the antiperistaltic motions do not press 
against the fundus, but directly upward. There is, therefore, less 
genuine vomiting than a mere overflow of the contents, which mostly 
takes place so easily that the babies are not disturbed by it. 

The treatment of such cases, if treatment be required at all, would 
consist in the application of some dietetic rules. The infant should 
have less food and at longer intervals ; should not be carried about 
immediately after meals ; ought not to be shaken or jolted, nor carried 
face downward. 

This overflow takes place, as a rule, immediately after the baby 
has been nursed ; at that time the milk is still fluid. If vomiting occur 
a little later, the milk will be coagulated; if, then, the milk be not 
coagulated, the stomach is not in a normal condition. In these cases, 
and particularly when the baby lives on artificial food, there are un- 
easiness and pain associated with the vomiting. An acid mucus is 



VOMITING. GASTRITIS 39 

expelled, together with the contents of the stomach; these are the 
cases in which antifermentatives, such as silver nitrate, bismuth, 
resorcin, are indicated. Sometimes antacids alone will suffice, as 
detailed above. 

Gastritis (Acute Gastric Catarrh). — The feeble, the anaemic, 
the convalescent, and the feverish are predisposed to this affection, 
but it may occur in the previously healthy as well. In all such children 
the production of normal gastric acid is diminished. Besides, in all 
of them the muscular power of the stomach is reduced. 

Cold or hot ingesta, too large quantities of food, acids, spices, irri- 
tant medicines, alcoholic drinks, fat meat, cake, decomposed food 
with its ferment, each may be the cause of acute gastric catarrh, and 
must be carefully avoided; dentition, as such, is not a cause. Expo- 
sure to changes of temperature is apt to produce gastritis, but the 
usual cause is improper food. A single small meal, consisting of 
(in that case) indigestible food, increases pain, vomiting, and fever. 
Abstinence and cold water to the head act well when there is a tendency 
to convulsions. Cold applications to the heart will also reduce the 
temperature of the whole body. A warm bath will frequently do 
good; but bathing and handling the child should proceed with great 
caution and very gently while a convulsion is lasting. When thirst 
is very great, small quantities of ice-water should be given often, or 
Seltzer-water, or Vichy, or Apollinaris ; also water to which dilute 
muriatic acid has been added in the proportion of one to three or 
ten thousand. 

Solid food must not be taken. When there is a great deal of 
mucus, milk should be given, if at all, very much diluted, or prepared 
after Rudisch's method. 

When the tendency to vomit is great, food and drink must be 
given in teaspoonful doses, and when the sensitiveness of the stomach 
is very marked, mucilaginous and farinaceous foods only will answer, 
together with small doses of bismuth repeated every one or two hours. 

When acid is predominant, calcined magnesia will answer best, 
if given in small doses frequently repeated ; also sodium bicarbonate, 
and very small doses of opium, one-sixtieth to one hundred and fiftieth 
of a grain, every hour or two hours. 

Chronic Gastric Catarrh is either the termination of an acute 
catarrh or of the persistent continuation of injurious influences. 
Large and frequent meals, too cold or too hot food, and fast eating 
are frequent causes. That is why bottle-feeding is preferable to 
drinking from a cup, and why'Heubner (Festschrift) emphasizes the 
necessity of under- rather than overfeeding children of early and of 



40 



FEEDING OF SICK CHILDREN 



advancing age. The stomach may be either in a hypersemic or 
in an anaemic condition ; it may be hypersesthetic or atonic. Its 
secretion may be deficient or faulty. All of these changes may take 
place in the stomach without any complication on the part of neighbor- 
ing organs, or these may be the only, or partial, causes of the gas- 
tric disorder ; thus pre-eminently cardiac or pulmonary ailments, which 
result in impaired circulation of the distant organs. Indeed, many a 
chronic catarrh of the stomach, both in the young and adult, requires 
among its first indications a proper attention to the original cause. 
At all events, the number of meals and the amount of food must be 
adapted to the digestive powers. Medication can do good service in 
most cases, either such as is directed to the mucous membrane itself 
(alkalies, bismuth), or to its faulty secretion (pepsin with muriatic 
acid, resorcin), or to the debilitated condition of its muscular power 
(strychnine). At all events, the children must be taught to eat 
slowly. Their food must be tepid and not too much diluted, inas- 
much as in many cases absorption is slow. Sugar, fat, and starch 
must be allowed in small quantities only. 

Ulcerations of the stomach (and duodenum) demand that the 
organs should be kept as alkaline as possible. Abnormal acids (acetic, 
butyric, caprylic, or lactic in excess) must be neutralized before food 
is given. An occasional antacid is not sufficient to attain that end ; 
it must be given regularly, every two or three hours, also a few 
minutes before a meal. Sodium and magnesium salts, which contain 
carbonic acid, should not be given regularly. That gas produces peri- 
stalsis. Calcined magnesia answers best in doses of one or two 
grains, administered every hour, or every two or three hours, in water 
which must not be too cold. Hot water is even better. More than 
that quantity is seldom tolerated because of its purgative effect (which, 
however, is very welcome, to a certain extent, in patients with a ten- 
dency to constipation) . When a larger quantity of antacids is required, 
prepared chalk or calcium phosphate may be added to the magnesium, 
with or without bismuth (subnitrate or) subcarbonate. In such a 
condition the effect of lime-water is in part imaginary. If given for 
the purpose of neutralizing strong acids, it is a failure. That medi- 
cinal treatment must be continued through weeks or months. With- 
out it I see no gastric or duodenal ulceration getting well, in spite of 
the most careful dietetic regulations. 

The very function of the diseased organ is a great danger. Both 
the stomach and duodenum must be kept as idle as possible and their 
labors made easy. No indigestible food must be given, no solid 
food permitted. Most cases in older children bear boiled milk (in 



GASTRIC ULCER. ENTERITIS 



41 



some mixed with a little sodium bicarbonate), strained oatmeal or 
barley gruel, rice or arrow-root water, and stale wheat bread; a 
few, also, raw beef, scraped. Some tolerate nothing but boiled milk, 
or buttermilk. There are those who prefer koumiss, matzoon, pepto- 
nized milk, or that prepared with muriatic acid. Whatever they take 
must be swallowed slowly. Milk, when drank hastily, is liable to 
coagulate in big, hard lumps, and proves indigestible and injurious. 
The same milk, when taken by the mouthfuls or from a spoon, will 
prove beneficial. The milk should be boiled in the morning and heated 
over again several times during the day, or it should be sterilized. It 
must not be cold when taken, and may be mixed with a very small 
quantity of table salt only. Quite often, to avoid the formation of 
hydrochloric acid in the stomach, salt should be withheld altogether. 
Many prefer and tolerate best the mixture of milk and cereal decoc- 
tions. Such must be the food for weeks and sometimes for months ; 
the meals must be small and more numerous. Thus the patients will 
get well, and thus only. 

Acute and Chronic Enteritis, Intestinal Catarrh, with 
diarrhoea as a prominent symptom, compare with acute and chronic 
gastritis in their mutual relation. Acute catarrh of some duration 
extends mostly over the whole intestine; its worst cases are also 
complicated with the same condition of the stomach. The most serious 
forms are those of " acute gastro-enteritis." In them the diet must 
be a very strict one. No raw milk, no boiled milk, no milk at all in 
any mixture, in bad cases. In the very worst cases total abstinence 
for from one to six hours, or much longer; afterwards, teaspoon 
doses of a mucilaginous or farinaceous decoction from time to time. 
A good preparation is the following: five ounces of barley-water, 
one or two drachms of brandy or whiskey, the white of one egg, 
salt, and cane-sugar; a teaspoonful every five or fifteen minutes, 
according to age or case. Later on a tablespoonful of boiled milk 
may be added. The same may be mixed with mutton-broth, which, 
with the white of egg, is better than beef-soup or beef-tea in con- 
valescence. In vomiting, abstinence is mostly superior to ice ; the 
latter may sometimes quiet the stomach and feel pleasant momentarily, 
but it stimulates peristalsis. Beef-tea, in its customary preparation, 
ought to be avoided. In convalescence, when given at all, it ought 
to be mixed with barley- or rice-water. Towards the end of the dis- 
ease, or when the discharges are numerous and copious, the blood 
becomes inspissated, the circulation slow, and thromboses (hydroen- 
cephaloid) arise in the smallest veins of distant organs. Then it 
becomes necessary to introduce liquid into the circulation by admin- 



42 FEEDING OF SICK CHILDREN 

istering water through the mouth or, if it tolerates it, the rectum; 
in desperate cases the infusion of a sterile salt-water solution (6 to 
iooo) into the subcutaneous tissue, once or repeatedly, may save 
life. Never are the common sense and tact of the intelligent practi- 
tioner more thoroughly taxed. In regard to that there can be no law. 
No printed rule ever supplies or substitutes brains. 

In chronic cases boiled milk must form but a small part of the 
food. The white of eggs in water, or in barley- or rice-water, is 
superior. Still, there are exceptional cases in which even they are 
not tolerated. Then the cereal and farinaceous preparations, with 
or without mutton-broth, are preferable. In rare cases one of the 
better artificial foods is quite successful. Acorn coffee, acorn cocoa, 
answer well when given once or twice daily. The meals must be 
small, and may be more numerous, but a fair regularity must be 
kept up. 

Constipation may have many causes. The intestinal mucus may 
be deficient or too viscid. Such is the case in febrile conditions, now 
and then in chronic intestinal hyperemia, and also when there is 
too much perspiration and secretion of urine. Or the food may be 
inappropriate, as when it contains a superabundance of casein, par- 
ticularly in cow's milk, or of starch, or too few salts, or of sugar. 

Peristalsis may be incomplete through rhachitic debility of the 
muscular layer or the muscular weakness dependent upon sedentary 
habits, chronic peritonitis, intestinal atrophy, and hydrocephalus. 

There is also, besides mechanical obstruction by cystic tumors, 
intussusceptions, volvulus, and imperforations, an apparent consti- 
pation which ought not to be mistaken for any of the above varieties. 
Now and then a child will appear to be constipated, have a move- 
ment every two or three days, and at the same time the amount of 
faeces discharged is very small. This apparent constipation is seen 
in very young infants rather than in those of more advanced age. 
Such children are emaciated, sometimes atrophic. They appear to 
be constipated because of lack of food, and not infrequently this 
apparent constipation is soon relieved by a sufficient amount of 
nutriment. Constipation resulting from a superabundance of starch 
in the food is easily cured by the withdrawal of the injurious sub- 
stance. 

Constipation produced by too much casein in the food will be 
relieved by diminishing its quantity. The proportion of casein in 
the food of infants should never be more than one per cent. Besides, 
this amount of casein ought to be copiously mixed with a glutinous 
decoction (oatmeal) as long as constipation lasts. 



CONSTIPATION. RHACHITIS 43 

Infants that have been fed on starchy food, or even such cereals 
as barley, should have oatmeal substituted for it. 

Constipation depending on lack of sugar is very often speedily 
relieved by increasing the quantity of sugar in the food. This is 
the case not only in artificial feeding, but also when the children 
are fed normally on breast-milk. Such mother's milk as is white and 
dense, and contains a large amount of casein, is made more digestible 
and will produce better evacuations when a piece of loaf-sugar dis- 
solved in tepid water or in oatmeal-water is given previously to every 
nursing. Older children will take honey to advantage as long as it 
does not add to the abnormal gastric acids, or a teaspoon ful of fresh 
butter, and should have a moderate dose of cream added to their 
food. Regular doses of cod-liver oil, given twice or three times daily, 
will obviate or relieve constipation, besides fulfilling other indications. 
But it is self-understood that it must be pure, and not adulterated 
by the fashionable admixture of calcium phosphate. Children of 
more advanced age and with good gastric digestion will be benefited 
by breads containing husk. Children of any age will be benefited by 
drinking large quantities of water. 

Rhachitis is sometimes the result of protracted intestinal dis- 
orders. Therefore proper feeding is an absolute necessity. Animal 
food must predominate, but meat ought to be lean. The so-called 
erethic rhachitis of thin, nervous children requires less meat, but 
more of the better clafss of farinaceous foods, — viz., barley and oat- 
meal, with boiled milk and salt. The same indications are valid for 
all the conditions subsumed under the head of scrofula. Coarse bread, 
acidulated food, and fruit not absolutely ripe should be avoided. The 
introduction of phosphates, in whatever shape, is a mistake, for the 
following reasons : 

In the careful experiments of Foster, who fed infants on milk, 
it was found that the mineral constituents were absorbed least (still 
less than fat). Of the ashes of milk, in general, there were in the 
faeces 36.5 per cent.; of the -calcium, in particular, seventy-five per 
cent. In spite of that the baby throve and increased in weight 
in one week one hundred and seventy grammes. Thus there ap- 
pears to be but very little need of salts on the part of the growing 
baby. The infant of two and a half years receives in one day 1.25 
grammes of calcium, of which there is an elimination of 0.92 gramme 
in the faeces and 0.03 in the urine. There is then a balance of 0.3 
gramme in a day, of 2.1 in a week, of a kilogramme, or two pounds 
of calcium, in a year. This is all that is utilized. 

Almost the entire quantity of calcium in the body is deposited in 



44 



FEEDING OF SICK CHILDREN 



the bones, which contain eleven per cent, of calcium in the adult and 
in the infant and child somewhat less. 

There are some very important practical points connected with the 
results of these observations. 

So long as the food contains plenty of calcium and phosphoric 
acid there is certainly no indication for the introduction of the same 
in the form of medicine, or as an addition to food, for the purpose 
of improving nutrition. Thus the combination of cod-liver oil with 
phosphate of lime, which has become so fashionable, is based upon 
an illusion concerning its alleged efficiency. Besides, the empirical 
observation has been made also, at a very early time, that immediately 
after the administration of preparations of calcium there was increased 
elimination through both the faeces and the urine. 

Thus, as there is no actual absence of calcium phosphate in the 
food, the organism should be spared useless labor. In occasional 
cases, where the effect appears to be favorable, this very effect is 
different from what was intended. When rhachitical or anaemic in- 
fants are supplied with phosphate of lime, iron, bismuth, etc., they 
are generally patients who are suffering from primary or secondary 
catarrh of the stomach, with superabundance of acid in its secretion. 
In these cases the calcium phosphate acts as an antacid, inasmuch 
as phosphoric acid becomes free and the lime neutralizes the acids 
of the digestive organs. 

Fever consumes nitrogen (eliminates urea), carbon, water, and 
also salts. These losses must be repaired, but with great care. 
For fever diminishes at the same time the secretion of saliva and 
of gastric juice, probably also that of the pancreatic secretion. Be- 
sides, it renders the stomach hyperaesthetic (nausea, vomiting) and 
impairs the absorbing power of all the mucous membranes. In the 
capillary bronchitis of the nursling, cow's milk is not digested satis- 
factorily. Still, nurslings will digest fairly sometimes, and lose less 
flesh in many of their febrile ailments than older children. A small 
amount of peptones is absorbed both in the stomach and rectum. 
In moderate fevers some sugar is absorbed, also albumin ; fat in 
but small quantities, because of its tendency to become acid; starch 
finds its saliva more or less diminished ; thus its amount must be 
carefully estimated. 

Food, when given in undue quantity, may act injuriously by 
causing a mechanical irritation and by giving rise to fermentation. 
Can it thus increase the fever? Undoubtedly. We frequently see 
children sick with pain and fever who recover rapidly through the 
effect of a purgative which brings away large masses of faeces. 



FEVER. TYPHOID FEVER 45 

Others have what appears to be a second relapse of typhoid fever, 
and often is but the result of intestinal autoinfection, with a renewal 
of splenic tumefaction. All the symptoms vanish speedily, in many 
instances, when the bowels are thoroughly emptied of large offensive 
stools. 

In ordinary fevers the food must be liquid and rather cool, in 
vomiting cold, in respiratory diseases warm, in collapse hot. The 
best feeding-time is the remission; in intermittent fevers nothing 
must be given during the attack except water or acidulated water, 
now and then with an alcoholic stimulant; in septic fevers nothing 
during a chill, except either cold or hot water, according to the wishes 
of the patient, with an alcoholic stimulant. Common ephemeral 
catarrhal fevers may do without food (except water) for a reason- 
able time. Sleep must not be disturbed, except in conditions of sepsis 
and depressed brain action. In both there is no sound sleep, but 
sopor, which should be interrupted. In sepsis (diphtheria and other) 
this rousing from sopor is an absolute necessity. Unless they are 
roused frequently to be fed sufficiently and stimulated freely the 
patients will die. Besides, in most of the cases the temperatures 
are not high and there is no contraindication to feeding on that 
account. 

Chronic inflammatory fevers bear and require feeding as generous 
as it must be careful. Altogether, however, it requires the good 
judgment of a well-informed physician to take into account the possi- 
ble influences of individual habits and energies, of ages and sexes, 
of constitutions, and of climate and season. 

Typhoid fever is of long duration ; its temperature is sometimes 
quite high in children, when of more advanced age. The lower part 
of the small intestines is affected principally. Thus, not only is, 
after the first few days, a fair amount of food required, but it must 
be so chosen as to be digestible in the upper part of the alimentary 
canal ; its proper selection is the more important the more the latter 
organ is impaired by high temperatures. Besides plenty of water or 
acidulated water (hydrochloric, no organic, acid), albuminoids are 
indicated. Milk and cereals (in decoctions, which must be strained) 
are the proper foods. The administration of stimulants, both as to 
quantity and to time, depends on the character of the individual case 
and the power of resistance on the part of the patient, besides on 
the condition of the heart. When the latter becomes feeble at an early 
period, besides heart stimulants (digitalis, sparteine, caffeine, cam- 
phor), alcoholic stimulants are required. Diarrhoea demands (besides 
opium, naphtalin) albumin, rice-water, arrow-root, mutton-broth. 



46 FEEDING OF SICK CHILDREN 

Hemorrhage, which fortunately is very rare in children, forbids food 
in any shape for a time, the duration of which depends on the general 
condition of the patient. At no time during the disease and during 
the first ten days of fully established convalescence should the food 
be solid. No purging vegetables must be allowed until three weeks 
have elapsed since the beginning of apyrexia. When milk and 
cereal food become distasteful, a change in their preparation, as 
described above, is indicated. During most of the time broths of 
mutton, beef, or chicken may also be given, or beef -juice or peptones 
diluted in water or in broths. The large majority of relapses are 
due to a dereliction in the strict rules of feeding. 

The diet in other chronic or acute diseases is regulated by the 
general rules which have been laid down before. Thus, a few words 
may suffice. 

FIereditary syphilis contraindicates the employment of a wet- 
nurse. The infant's own mother may nurse it if she can. 

Cerebral diseases contraindicate alcohol, coffee, hot soups, and 
solid foods. Cerebro-spinal meningitis results in speedy loss of weight 
and strength, particularly through severe and protracted vomiting and 
the greatly impaired appetite. In these cases feeding must be insisted 
upon. The feeding-cup and feeding through the nose (usually no 
tube into the cesophagus when there is much vomiting) must be 
resorted to. 

Respiratory diseases require liquid food. Jurgensen's recom- 
mendation of roasts, and of bread with butter (particularly the first), 
is objectionable in every acute inflammatory case. Food and drink 
must not be too cold. Sugar and sweets in general are permissible in 
small quantities only. Farinaceous foods are the most reliable ones. 
In the beginning no alcoholic stimulants. They will be required 
when debility and collapse set in at an early time or in protracted 
cases. Capillary bronchitis is often complicated with gastro-enteritis, 
and then no milk should be allowed ; sometimes even breast-milk is 
not digested. 

Acute renal diseases contraindicate alcohol in any shape, par- 
ticularly beer; also spices, coffee, and tea. Chronic renal dis- 
eases require generous feeding, because of the copious loss of albu- 
min. But — contrary to Oertel and Loewenmayer — no eggs or meats 
ought to be given in any quantity or at an early period. Milk and 
farinacea must take their places. Alcohol, as a stimulant, is per- 
missible in urgent cases only. Salt must be avoided except when the 
secretion of urine is to be fostered. It ought not to be forgotten 
that appetite and digestion may be suffering from the fact that the 



RENAL DISEASES. RECTAL ALIMENTATION 



47 



tissue of the stomach is ©edematous, like all the rest of the organs. 
This is another reason why eggs and meats ought to be avoided. 
If required in the later stages, peptones may take their place, but in 
small quantities only. Albumoses, such as somatose, are a good addi- 
tion to the food, easily borne and readily absorbed. Milk in any shape 
and preparation is the main article of diet. It has no such nuclein 
as favors the formation of uric acid, and no extractive matters which 
contraindicate the use of dark meats in diseases of the kidneys. Un- 
fortunately, it does not contain a sufficient quantity of iron to correct 
the loss of haemoglobin. That is why an exclusive milk diet is not 
borne a long time, and should be corrected by cereals and fruit. The 
old practice of administering chloride of iron finds its explanation 
therein. In renal dropsy water should not be withheld. In cardiac 
and hepatic dropsies it may be refused, but its absence in renal disease 
may cause anaemia and death. 

Acute rheumatism requires milk (also farinaceous) diet and 
vegetable acids (lemonade), the latter as long and at such times as 
thev do not interfere with the milk food. 



• RECTAL ALIMENTATION. 

The colon absorbs very readily both medicines (effective mostly in 
the same doses that are administered by the mouth) and foods, though 
more slowly. The caecum and rectum have this faculty more than 
the intermediate colon. Absorption may be increased by the greater 
pressure of large quantities (not always practicable in the living 
patient) or by local irritants, such as sodium sulphate. It is under- 
stood, however, that the colon cannot forever take the place of the 
upper part of the alimentary tract. A dog of Barbiani (Policlinico, 
1901) died of starvation in sixteen days, with a loss of two thousand 
five hundred grammes ; one with nutrient enemata without stimulation 
of the colon in twenty-six days, with a loss of two thousand nine 
hundred and sixty grammes ; a third one with chemical stimula- 
tion preceding his nutrient enemata in forty-three days, with a loss of 
three thousand grammes. 

The rectum absorbs carbohydrates, flour, wine, sodium chloride, 
sugar, egg (very slowly), but it does not digest. Whatever, there- 
fore, is to enter the circulation through the lower end of the alimentary 
canal must be dissolved before being injected. Suspension alone does 
not usually suffice. Water can be introduced in quantities of from 
twenty-five to one hundred grammes (one to three ounces) every 
one, two, or three hours, and may thus save life by adding to the 



48 FEEDING OF SICK CHILDREN 

contents of the thirsty lymph-ducts and empty blood-vessels. Salts 
in a mild solution, with cane-sugar, which is transformed into grape- 
sugar, and emulsionized fat, will thus be absorbed. Food must be more 
or less peptonized before being injected. Albumoses (for instance, 
" somatose") are readily absorbed in the rectum, so are also the pep- 
tones mentioned above when fairly diluted. When too thick they 
are not absorbed, become putrid, and a source of irritation. Milk 
ought to be peptonized. The white of one egg becomes absorbable 
through the addition of one gramme of sodium chloride. If nutri- 
tive enemata are given at regular intervals, the quantity of albu- 
minoids in each should not exceed twenty-five or thirty grammes (one 
ounce). Otherwise, putrefaction with its consequences will set in, 
both locally in the intestine and generally in its effect on the condition 
of the blood. Kussmaul beats two or three eggs with water, keeps 
the mixture for twelve hours, and injects it with some starch de- 
coction. The latter is partly changed into dextrin. Fat, when 
mixed with alcohol, is apt to be partly absorbed. Andrew H. Smith 
recommends the injection of blood. Its soluble albumin, salts, and 
water are readily absorbed; more we ought not to expect. Still, he 
has observed that the evacuations of the next day contained none 
of the injected blood. Whatever we do, however, and be the rectum 
ever so tolerant, not more than one-fourth part of the nutriment 
required for sustaining life can be obtained by rectal injections, and 
inanition will follow, though it be greatly delayed, and though the 
sensation of hunger be tolerable, particularly after one or two days 
have passed by. Finally, children are not so favorably situated in 
regard to nutritious enemata as adults. In these the lengthening 
of the nozzle of the syringe by means of an elastic catheter permits 
of the introduction of a large quantity of liquid; indeed, a pint and 
more may be injected and will be retained. But the great normal length 
of the sigmoid flexure in the infant and child, which results in its 
being bent upon itself, prevents the introduction of an instrument 
to a considerable height. It will bend upon itself ; besides, a large 
amount will not be retained by the feeble or resisting young patient. 
Moreover, the rectum is straight, the sacrum not very concave, and 
the sphincter feeble in the very young. The amount can be some- 
what increased by raising the baby by his feet, while the chest and 
abdomen are supported by a soft pillow, and by injecting quite slowly 
or, rather, allowing the liquid to flow in from above downward. 
While the procedure is going on the abdomen should be gently 
manipulated. When a long, solid instrument is used it is apt to be 
felt high up in the abdomen. This is the result of a large portion 



FORCIBLE FEEDING 



49 



of the intestine being pushed upward with the tube, and gives rise 
to mistakes as to the efficiency of your treatment. 

The ingenuity of the practitioner will sometimes be severely taxed 
in regard to the choice of the mixture to be injected. Boas recom- 
mends for an adult two hundred and fifty cubic centimetres (eight 
ounces) of milk, the yolks of two eggs, a gramme of table salt, a 
tablespoonful of claret, and a tablespoonful of diastased farinaceous 
food; Dujardin-Beaumetz, one glass of milk, the yolk of one egg, 
two or three tablespoonfuls of liquid peptone, five drops of laudanum, 
and one gramme of sodium bicarbonate. The injections ought not 
to be too watery, and of the temperature of the body. When the 
rectum is very sensitive, the addition of a mild opiate is advisable at 
all events ; sugar, alcohol, and whatever is apt to irritate the rectum 
should not be given in large quantities. Straining and abdominal 
pressure generally may be overcome by supporting the perineum and 
compressing the sphincter. (See also p. 66.) 

FORCIBLE FEEDING. 

When children or infants refuse or are unable to take food, forci- 
ble feeding should be resorted to. A proper amount of liquid food, 
from one-quarter of a pint to a pint or more, according to age or 
to circumstances, should be introduced into the stomach several times 
a day by means of a sound of proper size. The procedure need not 
last longer than a few minutes, and the tube should be drawn out 
quickly so as not to irritate the pharynx. 

Nasal feeding is best accomplished through a small funnel which, 
to avoid pain, terminates in a short piece of India-rubber tubing. 
This is introduced into the larger nostril, the patient is held firmly 
on his back, and just enough food is poured in to allow the child to 
swallow. A small syringe from which the piston has been withdrawn 
may take the place of the funnel. 



II 

General Therapeutics 

Therapeutics of infants and children has had its stages between 
the era of dull and ignorant prescribing and that of impotent and 
conceited nihilism and of churlish pessimism. But neither a deluge 
nor an absence of drugs makes a physician, nor do they contribute, 
when alone, to the welfare of a single individual or of the com- 
munity. 

The first indication in therapeutics is a correct diagnosis. The 
most efficient treatment is local, and the cause, seat, and essence 
of a morbid process should be known, or at least sought for. Many 
a diagnosis at the present time is still simply symptomatic, though 
less so than in bygone times. Half a century ago, or less, symptoms 
like paralysis, convulsion, dropsy, or jaundice were considered full- 
fledged and sufficiently scientific diagnoses ; to-day even chlorosis, 
pernicious anaemia, diabetes, epilepsy, and many others require etio- 
logical differentiation to be understood and appropriately treated. 
The most promising therapy of the future — serotherapy — owes its ori- 
gin and importance to nothing but an accurate bacteriological diag- 
nosis. 

Much has been said of the difficulty of a diagnosis in the diseases 
of infancy and childhood, and the consequent difficulty experienced 
in treating them. I do not believe that the diagnosis in the case of 
an adult is much easier; in many instances it is more difficult. The 
latter will often mislead you intentionally, or because he is carried 
away by prejudices and preconceived notions; the former may con- 
ceal by not being able to talk, but will certainly not tell an untruth. 
Besides, the ailments of children are rarely complicated, and usu- 
ally a single diagnosis tells the whole story. If it be not made, it 
is perhaps best for the practitioner not to attempt much doctoring, 
beyond the relief of the most urgent symptoms, and for the patient to 
be let alone. For, happily, most diseases have a tendency to get well, 
either completely or partially, and many will run a more favorable 
course when not meddled with. 

This does not mean, however, that I discourage treatment even 

in such ailments as run a typical course extending over a number 

of days or weeks. On the contrary, I am opposed to the practice — 

much too common — of those who do not, for instance, wish to inter- 

50 



EXPECTANT TREATMENT 5 1 

fere with a whooping-cough because it finds its natural termination 
after several months. This is true, but many of the children also 
find their natural termination during these months. Every day of 
whooping-cough is a positive danger. A lobular pneumonia which 
occurs in the second or third month of the disease, and proves fatal 
or terminates in tuberculosis, would have been prevented if the orig- 
inal affection had been removed or relieved by treatment. A physician 
advising no treatment in such cases as terminate unfavorably in this 
manner ought to be held responsible for his neglect. Nor do I 
approve of the practice of " meeting symptoms when they turn up." 
My responsibility is not lessened by my busying myself with subcuta- 
neous injections of brandy when a collapse has set in which I ought 
to have foreseen and prevented, or with giving digitalis when on 
the fifth or sixth day of a pneumonia the pulse is flying up to 160 
or 200. Anybody can perform that sort of perfunctory expectant 
treatment extending from the first call to the writing of a death 
certificate. What I expect of a physician is to know beforehand 
whether or not that individual heart will carry its owner through an 
inflammatory or infectious disease without requiring stimulation. 
Many a case might be saved by a few grains of digitalis or another 
cardiac tonic or a few efficient doses of camphor or musk, if adminis- 
tered in time.* 

Altogether, it has always appeared to me most satisfactory to treat 
children, and particularly infants. They are truthful, unsophisticated ; 
they are what they appear, and they appear what they are. In their 
pathology and therapeutics there is no mysticism, no faith-cure, no 
spiritism, nor any other diabolism. Their diseases are seldom influ- 
enced by mental impressions and emotions, and for that reason " sug- 
gestion," hypnotism, or any other confidence game has no power 
over them, certainly not to the same degree as over adults. But older 
children may be influenced to a certain extent. Neurasthenia, neural- 
gias, and hysteria are not unknown among them ; like strong irri- 
tations of the senses, the incautious causation of emotions and the 
awakening of autosuggestions may become dangers to psychical life 
and lead to somnambulism, hysteria, and intellectual and moral per- 

* " Our platform should be : In order to obtain indications for treatment 
make a diagnosis. That art is becoming both more accessible and, through 
honest and hard work, more easy with the aid of modern methods. Remember 
that most diseases have, indeed, a tendency to spontaneous recovery, but also 
that recovery is not always complete and that invalidism should not be invited 
through neglect of treatment." (Trans, of the Med. Soc. of the State of N. Y., 
1901.) 



52 GENERAL THERAPEUTICS 

versities of all kinds. Imitation, or emotional contagion, in a school- 
room leads to chorea, in a dormitory to enuresis. Children's nature 
and that of their ailments are simple enough, but you must know 
how to understand them. Unfortunately, however, for incompetent 
practitioners, children are no mere miniature editions of adults, and 
their ills and whims and peculiarities must be known, patiently 
studied, and, together with the ignorance and the prejudice and 
caprices of the parents, endured. 

Though pediatrics is no specialty like, for instance, ophthalmology, 
and the practice prevailing in Europe, mainly in Germany, on the part 
of those who are in the market for business and reputation, of adver- 
tising themselves as children's specialists (" Kinderarzt"), both ludi- 
crous and reprehensible, there is enough in the physiology and pathol- 
ogy of infancy and early childhood to justify the most careful atten- 
tion to their peculiarities, mainly on the part of those who have laid a 
solid foundation of general medical study. This is essential. That 
is why pediatrics should form the most important branch of the very 
last year — the fourth with us — of a medical curriculum. In the con- 
templation of the healthy and of the morbid condition of the young 
the first consideration is the imperfection of the tissues. Cell-growth 
is still or is apt to remain embryonal. That is why hemorrhages are 
so frequent soon after birth and why most tumors encountered in later 
life have a foetal origin. Voluntary and involuntary muscular action 
at that age is insufficient. Circulation is different from what it is 
to be, the heart is comparatively large and strong, the arteries in 
part larger (carotids, renal) compared with the size of the organs 
they supply, and compared with their own size as attained in later 
years. Digestion is not competent compared with that in adults. 
Its muscular action is defective, and the gastro-intestinal secretions 
not equal to those of advancing growth ; still, it should be known that 
the differences are not so great as prejudice or the obstinacy of often 
refuted impressions will have it. For to this very day there are innu- 
merable men who will simply not submit to what has often been and 
may easily be proven to be a fact, that the newly-born has a diastatic 
amylum-digesting ferment in his salivary glands. The nervous system 
of the newly-born is but little receptive, is still less apt to exhibit 
reflex action than later on ; in the young infant the inhibitory function 
is scantily developed. The most characteristic feature of the young 
is his growth; developmental diseases are very frequent. To this 
class belong those of the locomotor system, osteitis and epiphysitis 
of every kind, including spondylitis, rhachitis, and scoliosis; of the 
nervous system, such as meningitis and encephalitis ; of the lymphatic 



ANATOMICAL AND PHYSIOLOGICAL PREDISPOSITION 53 

system, such as adenoids, hypertrophies of the tonsils, adenitis, peri- 
adenitis, and polypi of the rectum. In close connection with his dis- 
orders is the congenital condition of mucous membranes. On the 
combination of the imperfect or morbid condition of those two rests 
the condition we call scrofula. The respiratory organs have their 
own peculiarities; their inflammations have a peculiar type in early 
years, and the narrowness of the larynx explains many of the immi- 
nent dangers connected with even a thin diphtheritic exudation. In- 
fectious fevers generally can be best studied in infancy and childhood. 
These are only a few instances proving that a large part of general and 
special nosology can be studied in infants and children only, and that 
both hygienic and drug therapeutics cannot be complete by far without 
the information drawn from the morbid conditions of infancy and early 
childhood. 

The period of puberty requires particular attention on the part 
of the therapeutist. There are sudden changes. The heart grows 
suddenly, the blood-vessels, formerly wide, are relatively narrower; 
the body grows, with it the head ; metabolism is very active, the mus- 
cles gain strength, the sexual organs develop and send to, and derive 
from, the central nervous system new sensations and impulses. He- 
reditary taints show themselves at that period, epilepsy and insanity 
reveal the neurotic taints of parents or grandparents ; so marked 
are such outbreaks of developmental origin that, when intermitting, 
they may return during the climacteric period. Growth may stop, 
however, at that time; small stature, deformity of the genitals (with 
or without hernia), absence of beard may explain and detect the pre- 
vious criminal. In milder cases there are general feebleness, neurosis, 
headaches, chlorosis, menstrual irregularities, changes of character, 
with or without onanism, or the onset of constitutional diseases. No 
new diseases need appear about this period, but the impressibility 
and vulnerability of the nervous system, the tendency to anaemia occa- 
sioned by the sudden growth, and the frequent lack of harmony in the 
development of the different organs are able to start hidden diseases 
and tendencies, and require the most painstaking care of the judicious 
practitioner in regard to diet, hygiene, and medicinal therapeutics. 

There is one all-important principle in treating infants and chil- 
dren which cannot be repeated too often. They are very liable to 
become anaemic, to submit to general inanition, and to suffer from 
failure of the heart in spite of its anatomical and physiological vigor. 
These facts render it urgent that the physician never lose sight of 
the general condition of the patient while attending to a local disorder. 

Good treatment is always preventive; it should save strength, if 



54 GENERAL THERAPEUTICS 

any be left, and provide at once for such comfort as will facilitate 
physiological functions. Do not insist, at the cost of a patient's life, 
upon having a very accurate local diagnosis when a pleuritic baby 
with a pulse of 180 and agony imprinted on its pinched, flushed face 
appeals for mercy. It may die while and because you are satisfying 
your " scientific" interest. Or when a patient, old or young, gets 
into a hospital ward after a tedious ambulance trip that exhausted 
whatever vitality was left, let there be no routine bathing and no close 
examination until the patient has been resting and a stimulant and 
probably food have been administered. To act differently may kill 
him. 

Then, attention must be paid to the way the sick are placed or 
kept in bed. As long as they are conscious they will aid the doctor 
in determining their posture; but grave infectious fevers, such as 
meningitis, influenza, typhoid, etc., impair consciousness and the self- 
protection it affords. A patient must not be allowed to rest on the 
same side always. Hypostatic congestion of a lung may be prevented 
or even cured by proper alternation. Gangrene may thus be pre- 
vented. Other suggestions which should force themselves on the 
attentive physician, and might be multiplied, are as follows. 

Congestion of the cranial cavity and meningitis require a rather 
erect or at least semi-recumbent posture. Convulsions thus origi- 
nating may be relieved by changing the horizontal position into one 
more vertical. Care should be taken, however, not to raise the head 
alone and thus interfere with the circulation of the neck. The trunk 
must be raised with the head at the same time. Be also sure that no 
feather pillow or mattress add to the internal heat. Anaemia of the 
brain requires a horizontal or nearly horizontal position ; temporary 
syncope, a temporary lowering of the head and upper part of the 
trunk even below the horizontal level. 

Spondylitis requires absolute rest on a mattress, no matter whether 
tuberculous or traumatic; the former is more frequent, and in its 
incipient stage may heal with rest and general proper treatment. 
The latter will, however, never suffice without the former. Marked 
rhachitis requires rest. Bending limbs should be discouraged from 
walking, softened cranial spots protected by a hollow air or hair 
pillow, and bending ribs and spine demand carrying in a well-lined 
brace (pasteboard, leather, wood, felt, wire) until after months the 
bones are sufficiently hardened. A rhachitic child should never be 
carried on the arm before the bones are hardened, and surely not 
persistently on the same (right) arm. Scoliosis is the invariable 
result. 



HYGIENIC DIRECTIONS. SCHOOLING 55 

Children suffering from retropharyngeal abscess, pharyngeal phleg- 
mon, or laryngeal obstruction bend their heads back to facilitate 
respiration. Until fully relieved, their heads should be supported 
in the position voluntarily assumed. In incipient pleurisy they will 
try to lie on the healthy side; when effusion has taken place, how- 
ever, on that of the effusion, to give fairer play to the healthy side. 
In local pneumonia, mainly of the upper lobe, a rather erect position 
is preferred; in a total pneumonia of a whole side or an extensive 
lower lobe affection most patients prefer a nearly horizontal position, 
with slightly raised head only, to permit extensive excursion of the 
diaphragm and the co-operation of abdominal respiration. Heart dis- 
eases with dilatation and hypertrophy and pericardial effusion require 
semi-recumbent position in bed or erect posture out of bed. Dilatation 
of a bronchus and abscess or gangrene of a lung demand posture on 
the healthy side ; thus expectoration of the putrefying or putrid mass 
is facilitated. Moreover, in that position the inhalation of disinfectants 
is rendered easier. During pulmonary hemorrhage the patient should, 
if possible, lie on the affected side to prevent to some extent the blood 
from running into the healthy lung. 

Proper feeding and nursing of the infant prevent the numerous 
gastric and intestinal diseases of the earliest period, which either 
destroy life at once or lay the foundation of continued ill health. For 
that reason a rather large part of my literary labors has been dedi- 
cated to the questions of diet and hygiene. These and medication 
belong together. That is why the first chapter of this work neces- 
sarily contained some remarks on medication, and this one, dedicated 
to therapeutics, cannot abstain from referring to diet. Those who 
still object to drug medication on the " principle" of ignorance, or 
worse, are requested to kindly determine the boundary line between 
medicinal and hygienic agents or products. Attention to respiration 
and circulation and to the functions of the skin are of similar moment. 
Their requirements will be discussed in special chapters. The subjects 
of climate, massage, electricity, orthopaedics, and gymnastics will find 
their places with the diseases of the lungs, muscles, nerves, joints, etc. 
Bathing, cold washing, exercise, and sufficiently long interruptions 
of school hours to avoid exhaustion are subjects of vital importance. 
Physicians and humanitarians have declaimed against premature 
schooling, too long hours, too short recesses, and objected to the 
overcrowding of the curriculum and to the vanity of incompetent 
school-masters and mistresses who utilize the poor victims in behalf of 
exhibitions ; mostly in vain thus far. A child of seven or nine years 
should not have more than two or three hours daily, one of which 



56 GENERAL THERAPEUTICS 

should be spared for intermediate recesses ; from nine to twelve years 
the school hours should be three or four, after that age not more than 
five hours, with frequent and ample recesses. If the mentally slow 
were taught separately, bodies and minds of all classes of children 
would be benefited beyond the possibilities of a hot-house instruction. 
The best exercise of the child is play in open air. Compulsory gym- 
nastics in badly ventilated localities cannot take its place successfully, 
and may add to exhaustion and ill health. It is an unfortunate fact 
that when the claims of physical development were urged upon school 
authorities, gymnastics were added to the overcrowded curriculum 
as a matter of business necessity, or of conviction, not always willingly 
or intelligently. The summer vacations of public school children 
ought to be four weeks longer than they are. The public schools 
ought to be closed about the middle of June and reopened in October. 
Many years ago the Harlem Medical Association and the Medical 
Society of the County of New York requested the Board of Educa- 
tion of the city to open the public schools on the third, in place of 
the first, Monday in September. The soundness of the principle was 
appreciated, and the necessity for such a change was acknowledged 
by the authorities, and therefore ( !) the second Monday of September 
was selected for the beginning of the school season, so as to afford the 
children an extra week's broiling in the city sun and an opportunity 
to lose, as they did formerly, the benefit derived from the summer 
vacation. The sanitary reason for this loss of a beneficent opportunity 
was said to be the virtuous anachronism of an eighteenth-century 
school superintendent, still in office in this twentieth century until a 
few months ago, who said he preferred the influence of the school- 
room to that of the New York streets for the New York boy. The 
good effects of the excursions of the St. John's Guild and the air 
funds and of the Sanitaria of the Guild and the Children's Aid 
Society, and many other sensible charities, are steps in the right 
direction. 

The beneficent influence of fresh air is enhanced by that of light. 
Rooms situated toward the north exhibit a musty odor compared with 
those directed toward the south. Sunlight oxidizes organic substances 
and destroys bacteria. Light without warmth has been recommended 
against bacilli, syphilis, furunculosis, and lupus. Others recommend 
against the latter light and warmth, as also against rheumatism where 
it is said to cause perspiration without urea, and against neuralgias ; 
the same is recommended for the increase of erythrocytes and haemo- 
globin. Old clinicians and physiologists appreciated the influence 
of light. Winslow charged insufficient light in the houses with being 



PHYSICAL REMEDIES. BATHING 



57 



the cause of retarded mental and physical development and of rha- 
chitis. Moleschott knew the slowness of metabolism in children when 
not exposed to light. In light the elimination of carbonic acid and the 
assimilation of oxygen are increased. In open air the temperature of 
the body is higher by 0.5 C. than in dwellings. It is true, however, 
there is the additional influence of air (and exercise?). 

The subject of bathing, or rather of hydrotherapeutics in general, 
deserves some preliminary remarks in connection with a future dis- 
cussion on " bathing." There is hardly a topic which deservedly has 
attracted the attention of the profession (and of the public) in the 
last decade or two to a greater degree than that of water and of its 
uses as a remedy. As I am writing no history, I mention but two 
(modern) names that merit most credit in outlining both the indi- 
cations and the methods of its uses, Winternitz, in Europe, and S. 
Baruch, in America. Cold water was long believed to have an anti- 
pyretic action only. Now the indication to reduce the temperature 
of the body arises when an excessive frequency of the pulse, degen- 
eration of the tissues of the heart and other muscles, of the kidneys 
and of the brain, dryness of the mucous membranes, and impairment 
of absorption appear to result from it, but from it alone. Cerebral 
symptoms, such as delirium and convulsions, are then not uncom- 
mon. Particularly is that so in the onset of a disease, while the 
same temperature may be readily endured at a later stage. That is 
why the elevation of temperature alone, without the above dangers 
either present or feared, should yield no indication for antipyretic 
treatment; indeed, many a child bears easily a temperature which 
carries danger to another; and there are high temperatures in some 
diseases, such as many forms of typhoid fever or of intestinal auto- 
infection, which do not seem to interfere much, for a while at least, 
with the ease and comfort of the patient. Unfortunately, however, 
the thermometer, ranging 103 F. or more, is often permitted to estab- 
lish indications, and the reduction of temperatures appears to become 
a fad and the only acknowledged duty of many practitioners. 

To reduce temperatures we have drugs and water. Of the former, 
quinine should not be relied on except in malaria, also in some septic 
fevers, when it may be used by itself or in combinations during re- 
missions. The coal-tar preparations, antipyrin, salopyrin, lactophenin, 
phenacetin, etc., will all reduce temperatures, and have their occa- 
sional indications, but are known to depress, one more the other less, 
the action of the nervous system and the functions of the heart, and 
even to destroy blood-corpuscles. Acetanilid has the latter effect 
more than any of the rest and should be discarded altogether. Their 



58 GENERAL THERAPEUTICS 

administration requires the utmost care, and frequently demands the 
combination with stimulants to guard against detrimental effects. 

The temperature of the young body is easily influenced by appar- 
ently slight causes ; it may rise and fall almost suddenly. A sudden 
rise and a continuous heat may prove dangerous; remissions and 
intermissions are loopholes for escape from dangers. These dangers 
are not so much the direct result of a high temperature as of the 
toxic effect of circulating microbes or their products. A moderate 
degree of temperature is well tolerated and should not be interfered 
with. In many cases it should be looked upon as a reaction of the 
organism only and in others should be considered welcome by its 
effect on the destruction of microbes and toxins and its favoring the 
formation of antitoxins in the infected blood and cells. Not infre- 
quently the very worst and most unmanageable cases of sepsis, 
diphtheritic, scarlatinous, or puerperal, run their bad or fatal course 
with low temperatures, while those with high temperatures will 
recover. 

Water, when properly employed, lowers the temperature, but has 
none of the depressing effects of the coal-tar antipyretics. On the 
contrary, it stimulates the nerves of the skin and by reflex those of 
the whole system, particularly of the heart;, it increases heart and 
arterial pressure, thereby aids oxidation of tissues and diuresis, and 
appears even to increase the amount of haemoglobin and of red cells. 
In this respect there can be no longer a difference of opinion ; but 
in regard to the use of cold washing, with or without friction or 
affusion, of packing, of ice applications, of hot, warm, or cold baths, 
of the duration of an application or of a bath, and of the degree of 
temperature requiring or permitting their employment in an individual 
case, no iron-clad rule will ever hold good. 

A cold bath (from 6o° to 75 ° F.) is seldom, if ever, appropriate 
for a baby of less than eight months or a year, and never in congenital 
heart disease. If given at all, it ought to be interrupted when the 
child begins to shiver or the lips become bluish ; it cannot be ex- 
pected to have a good effect unless the feet share immediately in 
the reaction which should take place after the bath. A cold bath 
should, according to circumstances, sometimes be preceded or fol- 
lowed by the administration of a stimulant, and usually not be extended 
beyond four or five minutes and be accompanied by friction of 
the surface, mainly of the extremities. A warm bath (from 85 ° to 
98 F.) differs so much from the temperature of a feverish child 
(from 101 to 107 F.) that a reduction will also be readily accom- 
plished by it. Besides, the patient submits to it more readily. The 



COLD, WARM, AND HOT WATER 59 

temperature of the bath decreases from minute to minute, or, if 
necessary, may be lowered by adding cold water. A warm bath, when 
given for the purpose of reducing temperatures, should last longer, — 
from five to fifteen minutes, — and may be given a number of times 
daily. After a cold bath the child should be covered warmly, particu- 
larly the feet, at least until the cutaneous circulation is fully restored ; 
after a warm bath the covers should not be too heavy, in order not to 
lose the benefit of copious radiation from the surface. Packs of cold 
water, iced or not, need not, in most cases ought not to cover the 
whole body of the child ; arms, feet, and legs should be left out. A single 
thickness of a common towel or napkin is wrapped around the body, 
exclusive of the arms, either the chest alone, or the abdomen alone, 
or both, and the thighs, according to the more local or more general 
effect which is to be attained ; and a layer of oil-silk or rubber cloth, 
and over it a flannel sheet or blanket should cover the pack. More 
minute instruction on this point will be found in Chapter III. To 
reduce local congestion or inflammation (conjunctivitis, peritonitis, 
arthritis, meningitis) cold water, ice-water, or ice-bags may be used. 
Small children do not tolerate ice applications to the head for any 
length of time, collapse resulting the more readily the thinner the 
skull. Applications should not be too wet ; small pieces of cloth cooled 
on a lump of ice should be frequently changed in cases of conjuncti- 
vitis. Extensive meningitis requires at least two ice-bags, the effect 
of which should be carefully watched. 

Cold applications, well wrung out and covered with flannel and 
oil-silk, to small or large surfaces, and allowed to remain from twenty 
to fifty minutes until the skin is hot, are efficient stimulants. Hot 
baths (from 96 ° to 105 ° F.) act as stimulants, but should be given 
sparingly and be of short duration, as too exciting or exhausting, 
when lasting long, for most patients. The head must be cooled while 
the body is immersed. Short hot baths, with or without mustard and 
with or without cold applications to the head, dilate the superficial 
blood-vessels, and will be found useful in an occasional case of pneu- 
monia, in collapse, or to favor the cutaneous eruptions of scarlatina 
and of measles. After removal from the bath, the patient should be 
covered with hot blankets, and a hot drink, such as water, an aromatic 
tea, or milk, should be given freely to promote perspiration. 

When bathing is resorted to as a means to lower or to increase 
blood-pressure, the effect of medicines given at the same time should 
be taken into consideration. Morphine lowers it, digitalis increases 
it; a bath to counteract the effect of morphine should have a lower 
temperature ; to relieve that of a dose of digitalis, a higher tempera- 



6o GENERAL THERAPEUTICS 

ture.* That is why the dose of a bath — that means its temperature 
and its duration — should be adapted to the normal and the morbid 
conditions of the individual patient. 

Because of its grave importance, I repeat here that milk and 
drinking-water are safest when boiled. It is to be hoped that, when- 
ever fresh and fairly sterile milk cannot be obtained, the method of 
sterilizing milk devised by Soxhlet, of Munich, and introduced in New 
York by Caille, and systematically employed by Rotch, of Boston, 
and his followers, will prove successful. Mental and physical labor 
ought to be easy and pleasant. Factory work for children is an abom- 
ination, and not only a cruelty committed against the individual help- 
less child, but a danger to the future of the republic, which cannot 
be expected to thrive while the physical and intellectual development 
of the future citizen is crippled by the greed of the manufacturer 
and the recklessness or the partiality of legislatures. 

It is evident, therefore, that preventive medicine is coming to the 
front as the main reliance of the future, in which the public-spirited 
and well-informed general practitioner will again be recognized as 
superior in breadth of horizon and good citizenship to the merely dex- 
terous specialist. Besides preventive medicine, drug therapeutics 
has not been left behind in the evolution of practical medicine. 
Since the times of Magendie, who supplied us with the first alkaloids, 
the laboratories of the pharmacologists, both in professional chairs 
and in factories, have added to our exact knowledge of drugs and 
their effects. At the same time physical therapeutics has developed 
simultaneously with drug therapeutics. The claim of some of the 
most modern writers, however, that physical therapeutics, such as 
hydrotherapy, electricity and galvanism, and the study of climate, is 
an accomplishment of the last few years, is not justified by the history 
of therapeutics. Only the books get bigger and sometimes out of pro- 
portion to our increased knowledge. Physical therapeutics has been 
extolled as " merely aids to natural processes," and " not medicines in 
the usual meaning" of the word. On that score superiority has been 
claimed for it. What that expression means I am at a loss to explain. 
I do not take a medicine to be a bullet that kills a disease from afar, 
nor a rope that strangles it. The enthusiasm of " physical therapeu- 
tists" has sometimes grown into fanaticism. Does physical thera- 
peutics militate against drugs? make them unnecessary, useless, or 
injurious? If water and massage and electricity are " natural" aids, 
are iron, digitalis, mercury, arsenic, alcoholics, or acids " unnatural"? 

* Karl Lewin, Phys.-Diat. Therapie, Wiener Klinik, No. 8, 1901. 



ADMINISTRATION OF MEDICINES 6l 

The narrowness of some minds cannot be better demonstrated than 
by the angry shopkeeper rivalry of doctrines or teachings or thera- 
peutical aids meant to work for the same legitimate and humane 
ends. 

In the administration of medicines excitement on the part of the 
patient must be avoided; the nervous system of infants and children 
loses its equilibrium very easily. Fear, pain, screaming, and strug- 
gling lead to disturbances of the circulation and to waste of strength. 
Preparations for local treatment or for the administration of a drug 
must be made out of sight, and the latter ought not to have an 
unnecessarily offensive taste. Naphtalin, iodoform, beta-naphtol, 
rhubarb, and such like should be shunned. The absence of proper 
attention to this requirement has been one of the principal commen- 
dations of " homoeopathy," whatever that may have been the last 
twenty or thirty years. Still, the final termination of the case and 
the welfare of the patient are the main objects in view, and the 
choice between a badly tasting medicine and a fine-looking funeral 
ought not to be difficult. In every case the digestive organs must 
be treated with proper respect; inanition is easily produced, and 
vomiting and diarrhoea must be avoided, unless there be a strict and 
urgent indication for either an emetic or a purgative. The most 
correct indications and most appropriate medicines fail when they 
disturb digestion; it is useless to lose the patient while his disease 
is being cured. 

The administration of a medicament is not always easily accom- 
plished. Indeed, it is a difficult task sometimes, but one in which 
the tact or clumsiness of the attendants has ample opportunity to 
become manifest. For " when two do the same thing, it is by no 
means the same thing." Always teach a nurse that a child cannot 
swallow as long as the spoon is between the teeth ; that it is advisable 
to depress the tongue for a moment and withdraw the spoon at 
once, and that now and then a momentary compression of the nose 
is a good adjuvant. That it is necessary to improve the taste as 
much as possible need not be repeated. Syrups turn sour in warm 
weather, glycerin and saccharin keep; the taste of quinine is cor- 
rected by coffee (infusion or syrup), chocolate, and " elixir adjuvans," 
a teaspoonful of which, when mixed each time before use, suffices 
to disguise one decigramme = one and a half grains of quinine sul- 
phate. Powders must be thoroughly moistened ; unless they be so, 
their adherence to the fauces is apt to produce vomiting. On the 
other hand, their prescription and preparation require care; for 
instance, many powders absorb moisture, such as acid phosphates, 



62 GENERAL THERAPEUTICS 

sodium bromide, calcium chloride, piperazin, lysidin, chloral hydrate, 
dry vegetable extracts, extracts of animal organs, citrate of iron 
and ammonium; others form a fluid when in combination, for in- 
stance, antipyrin; others, like iodides, resorcin, and aristol, change 
their color. Air-tight bottles or the addition of licorice powder cor- 
rect some of these changes. Capsules and wafers are out of the 
question because of their size; pills, when gelatin-coated or other- 
wise pleasant and small, are taken by many. The rectum and the 
nose may be utilized for the purpose of administering medicines in 
cases of trismus, cicatricial contraction, or obstreperousness. Both 
of these ways it may become necessary to resort to for weeks in 
succession. 

The rule not to prescribe incompatible medicines is valid at every 
period of life. For the treatment of children the following facts 
should be remembered. Corrosive sublimate should be dissolved in 
alcohol or in distilled water with the addition of sodium chloride. 
Calomel and iodides should not be given together or in close suc- 
cession ; calomel cannot be mixed with calcined magnesia ; potassium 
permanganate not with syrup, or with tannin, sulphur, glycerin, 
alcohol, or sweet spirit of nitre ; potassium chlorate not with car- 
bon or with sulphur ; alkalies not with alkaloids ; gallic acid not 
with alkaloids or albumin. 

The effect of a medicine depends on its dose and the readiness 
with which absorption and elimination take place. Medication, when 
its effect is wanted speedily, should be continued during the night ; 
mainly in such patients as have healthy kidneys. In infants and chil- 
dren sodium salicylate, for instance, is readily eliminated, much more 
rapidly than in advanced age. Both absorption and elimination are 
very active in infancy and childhood; but they vary. Curare, for 
instance, is eliminated speedily, and must be repeated quite frequently ; 
potassium iodide soon after its administration, but there are traces 
in the urine after some days ; phosphate of lime appears in the urine 
and faeces directly ; potassium chlorate is excreted through the kid- 
neys within a few hours ; silver and mercury may take a long time 
in exceptional cases. Absorption takes place the more readily the 
more the* solution in which the medicinal substance is held is diluted ; 
but it depends greatly on the condition of the surface or tissue which 
is selected for the introduction of the drug. A horny skin absorbs 
but little ; inunctions require a clean surface, and are best made where 
the epidermis is thin and the net of lymph-ducts very extensive, on 
the inner aspect of the forearm and the thigh. A congested stomach, 
a catarrhal or ulcerated rectum, are more or less indolent and disap- 



DOSES AND METHODS OF MEDICATION 63 

point our expectations quite frequently. High temperatures of the 
body exert their influence on mucous membranes and their secretions 
and absorbing powers, so that absorption and efficacy are diminished 
or annihilated. That the doses must be adapted to the ages of the 
patients is self-understood; but to establish fixed rules is more than 
merely difficult. To give as many twentieths of the dose of an adult 
as the child has years is a fair average; but this rule suffers from 
very numerous exceptions, like all the other rules that have been 
decided upon not at the bedside but at the writing-table. Like foods 
which are tolerated by the adult, but are not tolerated by the young, 
though the amounts be diminished in proportion to their years, 
so there are medicines which are not borne by the infant. Nor are 
the doses the same for every adult. As healthy persons thrive on 
different quantities of food, so there is a variableness in the amount 
of medicines required for full effect. Besides, there are idiosyncrasies 
which in some forbid the use of a medicine apparently indicated and 
borne with success by others. There are those who respond quickly, 
and sometimes too quickly, to very small doses of opium ; others in 
whom a minute trifle of mercury produces salivation. It is this 
class of cases which gives rise to much disappointment and requires 
all the tact and foresight of a good physician. In some the system 
gets used to a drug after a short time. Babies, after having taken 
opiates for some time, demand larger, and sometimes quite large, 
doses to yield a sufficient effect. Excessive doses continued a long 
time have produced morphinism in children as in adults. Some drugs 
are required in proportionately large doses. Febrifuges and cardiac 
tonics, such as quinine, antipyrin, digitalis, strophanthus, sparteine, 
and convallaria, are tolerated and demanded by infants and children 
in larger doses than the ages of the patients would appear to justify. 
Potassium iodide may be given in doses of one or two drachms 
(four or eight grammes) daily in meningeal affections, while in 
the same one of the heart tonics, caffeine, must be shunned because 
of its — under these circumstances — exciting and irritating effects. 
The same may be said of alcohol, which must not be administered 
in cerebral congestions unless they be of septic origin. Mercurials 
affect the gums very much less in the young than in advanced age. 
Corrosive sublimate, in watery solutions of one to eight or twelve 
thousand, may be given to a baby of two years with membranous 
croup in doses of a fiftieth of a grain every hour or two hours for 
five or six days in succession, with rarely as much as the most trifling 
irritation of the gums or of the stomach and intestines. In urgent 
cases of hereditary syphilis it can and should be administered on a 



64 GENERAL THERAPEUTICS 

similar plan for weeks, and, somewhat modified, for many months, 
to be resumed after an interruption of weeks, and later on of 
months. 

If it be the object of medication to accomplish an end and to fulfil 
an indication with the least expense to the organic economy, and 
within the briefest possible time, we do not score a success in very 
many instances. Indeed, not every aim is reached directly and not 
all indications can be fulfilled at a moment's notice. As the object 
of eating and drinking is the reproduction and the growth of the 
body, as many a meal is required to produce a lasting and visible 
effect, and as every one of the meals is necessary for the sum total 
of the final results, so the administration of numerous small doses 
of medicines extending over weeks, months, and even years may be 
demanded for a certain purpose. Particularly is this so when chronic 
ailments of the blood, the nervous system, or tissue anomalies are 
concerned. To affect rhachitis, phosphorus requires weeks. The 
faulty sanguification of chlorosis is mended by iron, if at all, after 
weeks or months. Pernicious anaemia, sarcomatosis, even chorea re- 
quire the persistent and protracted use of gradually increasing doses 
of arsenic. Syphilis and chronic conditions of hyperplasia require 
mercury or the iodides, or both, to accomplish the desired end, through 
months and even years. The organotherapy of myxcedema or of 
cretinism has to be continued for months and years and resumed 
after interruptions. Even the effect of digitalis, as a heart stimulant 
and, by its effect on the smallest blood-vessels of the heart muscle, 
a nutrient of the heart itself, is obtained solely through the persevering 
administration of small doses in many chronic cases. 

The dose of a medicine depends no less on the mode and locality 
of its administration. Modern therapeutics favors as much as possible 
local medication, like modern pathology, which requires local diag- 
noses. Subcutaneous administration demands smaller doses, the rec- 
tum sometimes a slight increase. There are some medicines which 
are absorbed and act as well in the rectum as through the mouth ; 
this is a subject, however, to which we shall return. The manner 
of application results also in different effects. The inunction of the 
official ointment of potassium iodide is well-nigh inert; its effect 
is almost exclusively that of massage, for iodine makes its appearance 
in the urine after days only. Potassium iodide in glycerin, rubbed 
into the skin a number of times, may eliminate iodine after a day, 
in lanolin after a very few hours. 

At this place it is well to remember the great additions to our 
therapeutical possibilities, though in a few words only. Our materia 



INTERNAL SECRETION. ORGANOTHERAPY 65 

medica has been enriched with alkaloids and enabled us to give invari- 
able and exact doses and to render medicines palatable, — advantages 
much greater than those derived from electrotherapy, Rontgentherapy, 
or even hydrotherapy. The gigantic strides of chemistry have fur- 
nished a large number of synthetic drugs, many of them of great 
efficacy for good or (and) evil, and some very creditable to both 
the learning and enterprise of manufacturers. Serotherapy and the 
medication supplied by the thorough study of the ductless glands 
are in part due to them. But, after all, the weapons our ancestors had 
in the shape of mercury, iodine, opium, digitalis, and others have 
not become dull ; indeed, modernized medicine has nothing like them, 
just as not one of the later or latest modern means of diagnosis excels 
or equals percussion and auscultation as taught eighty years ago. 

Of serotherapy I shall speak again; organotherapy may be men- 
tioned here. It was introduced to meet the dangers of the absence 
of " internal secretion." This is a term extensively employed, at 
first in regard to the adrenals {Brit. Med. Journ., August 10, 1895), 
by Schaefer and Oliver, and generally admitted to be descriptive and 
telling. It is applied to some of the processes, partly physiological 
and partly chemical, of the formation and disintegration of material 
in different parts of the organism. Saliva, gastric and pancreatic 
juice, and bile are external secretions, and carried off by efferent 
ducts. Internal secretion, however, requires no efferent ducts, indeed, 
no glandular stricture, for it occurs also in muscle and in brain sub- 
stance. Internal secretion is carried off into the lymph and blood 
directly. Liver and pancreas appear to have both external and inter- 
nal secretions ; but the thyroid, thymus, spleen, and adrenals appear to 
have internal secretion only. Their absence or removal or destruction 
by disease causes death with the symptoms of a chronic infection. 
This may result from one of two sources, or from both. Either those 
organs have the function of forming certain materials required in the 
organic economy, or that of destroying poisonous effete results of 
metamorphosis. Thus the absence or destruction or extirpation of 
the thyroid causes cachexia, that of the pancreas diabetes, that of 
the adrenals often Addison's disease. In regard to the thyroid, we 
are now certain that myxcedema and some forms of cretinism are favor- 
ably influenced, or even cured, by the administration of the thyroid 
gland of animals. More particulars will be found under the headings 
of myxcedema, cretinism, exophthalmic goitre, and others. 

At best, organotherapy requires patience and time. Some of 
its effects cannot be obtained except by administering the substitute 
for the absent or defective organ persistently. Myxcedema and semi- 

5 



66 GENERAL THERAPEUTICS 

cretinism are liable to relapse when medication ceases or is unduly 
interrupted. This will not be corrected, it is to be feared, until a 
normal organ is implanted into the suffering organism and made 
to perform its physiological functions. Thus far surgery has not 
succeeded in yielding the coveted results. 

The rectum of the infant and child has been rising in the esti- 
mation of the practitioner since the times of thermometry ; for it 
is certainly the safest and easiest place to take the temperature. 
For therapeutical measures it is also invaluable. Its importance for 
the purposes of alimentation has been detailed in a former chapter. 
(See p. 47.) 

The rectum of the young is straight, the sacrum but little concave, 
the sphincter ani feeble, and self-control is attained only gradually. 
Thus a rectal injection is easily either allowed to flow out or vehe- 
mently expelled. Therefore one which is expected to be retained 
must not irritate. The blandest and mildest is a solution of six or 
seven parts of sodium chloride in a thousand parts of water (" saline 
solution"). This may be made to serve as a vehicle of medicine, 
unless incompatible with the latter, which it will be but rarely. A 
medicated enema which is to be retained should be tepid and small 
in quantity, half an ounce or little more or less, and carried up well 
into the rectum, for the immediate contact with the sphincter may 
cause its expulsion. Care must be taken to exclude air from the 
syringe, which, for small quantities, must be a well-fitting piston 
syringe of hard rubber, with a long nozzle. This must be well oiled, 
and introduced, not straight, but with a gentle turn, so as to avoid 
folds in the anal mucous membrane (in the same way a thermometer 
ought to be introduced). The nozzle must not be too thin, as it 
is liable to be caught; the smallest nozzles of fountain syringes are 
therefore in most cases improper ; the larger size is more appropriate 
for any age. The injection must be made while the patient is lying 
on his side, not on his belly over the lap of the nurse, for in this 
position the space inside the narrow infantile pelvis is reduced to almost 
nothing. 

When medicines are to be injected, the rectum ought to be empty, 
as in infants it mostly is. When it is not, an evacuating injection 
ought to precede the medicinal one by half an hour. It ought to be 
of the mildest possible nature, for any irritation of the rectum, from 
the local effect of an enema to a catarrhal or dysenteric process, re- 
duces its faculty of absorption. The medicinal solution must not 
be saturated ; indeed, very soluble medicaments only are to be selected 



MEDICINAL AND EVACUANT ENEMATA 67 

for medicinal enemata. Nor must they be acid or contain anything 
irritating. Alcoholic tinctures require relatively large quantities of 
water; quinine salts must not be selected unless very soluble, such 
as the muriate, the bromide, the carbamide (bimuriate with urea), 
or the bisulphate. The addition of a small amount of antipyrin renders 
quinine very soluble. No acids must be used for the purpose of 
keeping it in solution. Sodium salicylate, also antipyrin, exhibit 
their full power through the rectum, and permit of full doses. Fre- 
quently, however, the rectal doses are a little larger than those given 
by the mouth. 

Larger enemata are not retained, and are therefore utilized for 
the purpose of emptying the bowels. This effect is easily obtained 
in infants and children, for their feces are soft and movable, with 
the exception of those cases in which improper medicines (large and 
continued doses of calcium salts and bismuth or astringents), or badly 
selected food (casein and starch in undue quantities), or an excess 
of the normal great length of the colon descendens and sigmoid flex- 
ure have given rise to large accumulations of hardened faeces. Small 
quantities are seldom sufficient for the purpose of relieving the bowels, 
unless they act as irritants ; in this manner glycerin, pure or with 
equal parts of water, may produce an evacuation readily. Irritants, 
however, should not often be used, for obvious reasons. An evacuant 
injection may weigh from a fluidounce to a quart, in some. It 
ought to be given while the child is lying down ; the liquid must 
not enter the bowels quickly or vehemently, the fountain syringe not 
hang more than ten or twelve inches above the anus. If that pre-- 
caution be observed, occasional pain or faintness or vomiting can be 
avoided. If water, or water with two-thirds of one per cent, of salt, 
be insufficient now and then, more salt or soap may be added for 
the purpose of enforcing the evacuation. Half a tablespoonful of oil 
of turpentine, with a pint of soap and water, often acts charmingly; 
so does the addition of a few drachms of tincture of assafcetida, in 
conditions of constipation, flatulency, and nervous excitability, also 
in convulsions ; or glycerin in obstinate constipation. A few ounces 
of olive oil is often preferable, as an evacuant, to anything else. 

Large injections will have other indications besides that of evacua- 
tion of the bowels. In many cases of intense intestinal catarrh large 
and hot (from 104 to 108 F.) enemata will relieve the irritability of 
the bowels and contribute to recovery. They should be repeated 
several times daily. When such evacuations contain a great deal of 
sticky, viscid mucus, the addition of one per cent, of sodium carbon- 
ate will liquefy the tough secretion. When there are many stools, and 



68 GENERAL THERAPEUTICS 

these complicated with tenesmus, an injection, tepid or hot, must 
or may be made after every defecation, and will speedily relieve the 
tenesmus. In such cases flaxseed tea or thin mucilage may be sub- 
stituted for water. 

When the bowels are in a state of chronic catarrh or ulceration, 
the injections ought to be particularly large and contain astringent 
or alterant medicines. Though they be expelled immediately, enough 
of the dissolved or suspended remedy will remain upon the mucous 
membrane. Zinc sulphate, alum, lead acetate, tannic acid, silver ni- 
trate, salicylic acid, carbolic acid, and creosote have been used in such 
medicated injections. One-per-cent. solutions will suffice. Salicylic 
and carbolic acids may prove uncomfortable or dangerous because 
of their effect on the kidneys, and ought to be dispensed with. Silver 
nitrate requires some precaution. From half a grain to five grains 
or more in an ounce of distilled water may safely be injected ; but 
this enema must be preceded by an evacuant consisting of water only, 
and followed by one containing some sodium chloride for the pur- 
pose of neutralizing the nitrate and protecting the anus and ex- 
ternal parts from local irritation. It will also be found advantageous 
to wash the anus and perineum with salt water before injecting the 
silver solution. In many cases where one of the above-mentioned 
agents appeared to be tolerated badly or proved inefficient, bismuth 
(or subcarbonate) subnitrate, mixed with water or with gum-acacia 
water in different proportions, proved very acceptable and healthful. 

Suppositories are useful both for evacuating and medicinal pur- 
poses. Soap is utilized for the former purpose by the public at large, 
and the same material differently mixed, with or without medicinal 
additions, such as atropine, by the irregular trade. Local medicinal 
applications to the rectum are best made by means of injections, but 
a general effect is also obtained through a suppository. Opiates, and 
narcotics generally, exhibit their full power when the suppository 
is retained. Extract of hyoscyamus, from half a grain to a grain in 
a suppository, to be repeated from two to five times daily, shows its 
effect in relieving vesical spasm nearly as well as when taken inter- 
nally. Quinine is gradually dissolved and absorbed. Extract of mix, 
both in ointments and in suppositories, acts well in prolapse of the 
rectum and debility of the sphincter. 

Subcutaneous injections of remedial agents ought to be made more 
frequently than appears to be customary. The extremities, particu- 
larly their lower halves, should be avoided, for their constant motion 
and the relative absence of fat in their subcutaneous tissues are liable 



SUPPOSITORIES. SUBCUTANEOUS INJECTIONS 69 

to give rise to local irritation, swelling, or suppuration. The abdomi- 
nal wall or the lumbar region is preferable. The recommendation 
to use the interscapular space was made by famous men who worked 
in the laboratory and did not know what inconvenience there may be 
in a back, punctured and often sensitive, on which a patient is to seek 
his rest. A sharp and aseptic needle and gentle friction of the injected 
part are all that is required. The solutions used must be clear and 
without any solid ingredients. When they have been preserved for 
some time they ought to be filtered before being used, particularly 
when fungous growths have begun to make their appearance in the 
liquid. The latter may be preserved best by adding a small quantity 
of alcohol, salicylic acid, or hydrocyanic acid. The doses must be as 
small as possible, and the medicine diluted more than in the case of 
adults. This is mainly required when a caustic effect is to be feared. 
While, for instance, Lewin advised for adults a solution of four grains 
of hydrargyrum bichloride in an ounce of water, one or one and 
a half grains give a more appropriate solution for infants. One or 
two daily doses of eight or ten drops continued for weeks will prove 
very useful in those urgent cases of hereditary syphilis which are 
characterized by pemphigus on the soles of the feet and the palms 
of the hands in the first days after birth. Brandy and ether may be 
used undiluted as in adults, but the latter is particularly painful and 
the greatest care must be taken as to the locality injected. The sub- 
cutaneous tissue must be reached and the cutis penetrated by inserting 
the needle at a nearly right angle from the surface. Chloral hydrate 
dissolves readily in two parts of water, but a solution of one in four 
or six is better tolerated. For the ready symptomatic treatment of 
convulsions it renders good service. Antipyrin is well borne in solu- 
tions of one in six or eight parts of water, camphor in from four to six 
parts of sweet almond oil. The fluid extracts of digitalis and ergot 
are very apt to give rise to indurations and, perhaps, abscesses. As 
a rule, the most convenient medicaments for hypodermic adminis- 
tration are the very soluble alkaloids. One or three drops of Magen- 
die's solution of morphine or the corresponding solution of morphine 
muriate are vastly preferable to the internal use of narcotics for 
bad pain in pleuritis or pleuropneumonia, or in peritonitis of advanced 
childhood. It may be mixed with atropine sulphate for the reasons 
regulating its use in the adult. The latter by itself has been found 
quite effective in the case of an epileptic boy, who had taken the same 
drug internally without any success. If possible, it ought to be injected 
during the aura ; if not, twice a day. Apomorphine muriate is a ready 
emetic in doses of a thirtieth or a fifteenth of a grain. Pilocarpine 



70 GENERAL THERAPEUTICS 

muriate can be injected in doses of from one-twentieth to one-eighth 
of a grain. Its reckless use, both hypodermically and internally, has 
led to occasional mishaps, but the drug is a powerful agent for 
good when carefully applied, and has saved for me several cases of 
meningeal hyperemia and cerebral oedema, mostly of nephritic origin. 
Strychnine sulphate, while in the same affections it has mostly proved 
inefficient when taken internally, has rendered efficient services in 
enuresis depending on paralysis or weakness of the sphincter of the 
bladder and in prolapse of the rectum and fecal incontinence resulting 
from paralysis of the anus which depended either on disease or con- 
genital incompetency. In these cases a daily dose of a fortieth or a 
twenty-fifth of a grain — according to the age of the patient or the 
severity of the case — is sufficient. More frequent doses, however, are 
required in the diphtheritic paralysis of the respiratory muscles, which 
is dangerous and apt to become fatal unless speedily relieved. A daily 
dose will also yield fair results, when long continued, in the later 
stages of spinal or cerebral paralysis, where its internal administration 
is entirely or well-nigh useless. Quinine salts must be neutral when 
injected; I prefer the bromide, the muriate, or the carbamide. They, 
particularly the last, are among the most soluble. The carbamide 
dissolves readily in from four to six parts of warm water; the latter 
temperature ought to be preferred in every case of subcutaneous injec- 
tions. Quite saturated solutions ought to be avoided, because it has 
happened to me that the water of the solution was speedily absorbed, 
and the quinine remained as a foreign body in the subcutaneous 
tissue. Caffeine, in combination with sodium and salicylic or ben- 
zoic acid, is an excellent heart stimulant, and has rendered splendid 
service in urgent cases of heart-failure or pulmonary oedema de- 
pending on cardiac disease. Sodio-caffeine salicylate and benzoate 
are soluble in two parts of water, and are readily absorbed. Both 
should be avoided in those cases which are complicated with cere- 
bral irritation or sleeplessness. Fowler's solution, carefully filtered 
and diluted with at least twice its quantity of distilled water, may 
be injected into healthy or morbid tissues without often risking 
irritation and abscess. Still, I have seen a splenic abscess after such 
an injection in a case of sarcoma of the spleen. Undoubtedly, the 
continued use of arsenic renders very efficient services in sarcoma; 
but as it has to be used quite a long time, it is almost impossible, except 
in hospital practice, to resort to hypodermic medication. There is no 
harm in this, however; for a slow, gradual increase of the drug is 
tolerated by the stomach to such an extent that very large doses 
(amounting to half a drachm = two cubic centimetres) of Fowler's 



SEROTHERAPY 



71 



solution daily, well diluted, may finally be administered after meals 
to children of six or eight years. 

Subcutaneous injections have reached an extensive field of use- 
fulness in serotherapy. After it was proved that animals could be 
immunized against certain virulent bacteria, it was found that the 
blood-serums of previously immunized animals * could be utilized 
as powerful remedies in infectious diseases of man. In the article 
on diphtheria more will be said of the effect of its antitoxin, the 
preparation and knowledge of which is due to Aronson, Roux, and 
Behring. Tetanus and diphtheria are certainly influenced by their 
proper antitoxins to a remarkable degree. Asiatic cholera is likely 
to be the next great scourge of mankind to be stripped by its antitoxin 
(Haffkin) of part of its fury. Neither Marmorek nor others, how- 
ever, have thus far succeeded in producing an antitoxin which is as 
effective as those of (tetanus and of) diphtheria in such infectious 
diseases as appear to be connected with, or dependent on, streptococci 
(puerperal diseases, erysipelas, scarlatina, and some forms of abscesses, 
of angina, and of mixed diphtheria). Nor are the claims of Coley, 
who, with antitoxin procured from the coccus of erysipelas and from 
bacillus prodigiosus, exhibits interesting results in sarcomatosis (not 
in carcinosis), generally accepted by all. In many more diseases anti- 
toxins have been recommended; prematurely it appears, for neither 
croupous pneumonia nor typhoid fever nor syphilis has been benefited 
thus far. Nor have the attempts at obtaining an antitoxin to take 
the place of calf vaccinia in the immunization against variola been 
successful. Not infrequently the lymph usually employed is mixed 
with bacteria and other impurities. The cases of tetanus appearing 
after vaccination should not shake the faith in vaccination nor relax 
the efforts to make vaccination compulsory, but should be a warning 
against careless preparation of vaccine. Thus far, however, a sterile 
blood-serum of the vaccinated calf cannot be obtained in sufficient 
condensation and efficacy. 

In organotherapeutics the hypodermic method is no longer em- 
ployed extensively, since the internal administration of the different 



* Not to be mistaken for the congenital protection afforded by the presence 
of " alexins" in the blood-serum of the newly-born. 

Certain infectious diseases leave in the circulation an immunizing sub- 
stance which protects its bearer against relapses. This, at least, is the only 
possible explanation of their protection. This fact suggested the possibility 
of a successful treatment of measles, pneumonia, and scarlatina with the blood- 
serum of such persons as had just passed through one of those maladies. Good 
results are reported. Personal experience I have none. 



72 GENERAL THERAPEUTICS 

tissues, or their extracts, or other modes of preparations is both 
efficient and (mostly) palatable. Many of the secretions and tissues 
of the body of man and beast were used in olden times under the 
reign of crude empiricism or bestiality, — blood, bile, urine, faeces, hair, 
bones, etc. Of the modern organ extracts, cerebrin, hepatin, lienin, 
renin, pulmonin, oophorin, spermin, didymin, the reports on which 
are not all dictated by an unpolluted scientific spirit, not much can be 
said as yet. Those which have been proven to be valuable, particu- 
larly to children, will be discussed later. 

The subcutaneous injections of cpcaine, according to Schleich's 
method of " anaesthesia by infiltration," will prove a great gain to 
the practitioner, inasmuch as, with or without the previous use of 
ethyl chloride, it will facilitate many operations. Maybe its principal 
advantage will lie in this, that many abscesses and furuncles will be 
dealt with before they are permitted to get larger. Their anti- 
neuralgic action will not be required frequently, because of the relative 
scarcity of neuralgias in childhood. In almost every case the solution 
is to consist of cocaine muriate o.i, morphine sulphate 0.02, sodium 
chloride 0.2, distilled water 100.0 (5 to 1 to 10 to 5000). 

Inhalation is resorted to in two different ways. Either the air 
of the room or of a tent is impregnated with the substances to be 
introduced into the air-passages, or these "substances are introduced 
through sprays or atomizers of different shapes and patterns. Some 
of the latter have always appeared to me very faulty and not to the 
purpose at all. Tubes introduced into the mouth, through which 
substances are to be carried down, will land them in the mouth ; 
it takes all the self-control and intelligence of an adult patient to 
allow the object in view to be accomplished. The oral cavity of the 
infant or child is small, the tongue is coiled up, and the faucial 
muscles will not relax. Nose and mouth must co-operate to allow 
inhalations to enter the larynx, or the former alone must be relied on. 
A spray calculated to reach the larynx of infants or children is always 
best introduced into and through the nose. In this way, at all events, 
the posterior part of the pharynx and the respiratory tract are reached 
to best advantage. The manner in which the spray is employed in dis- 
eases of the nose and pharynx is quite often too perfunctory, with no 
other result but to make the patients wakeful and restive ; and it should 
not be forgotten that no access to the trachea and bronchi is possible 
except during a deep inspiration. The difficulty of accomplishing 
that in children is obvious. 

Real inhalation, however, means filling the lungs with a gas or 



INHALATION 73 

vapor. Warm steam will do good service in bronchitis and pneu- 
monia, when the bronchial secretion is viscid and expectoration diffi- 
cult, and in diphtheria, for the purpose of softening membranes and 
increasing the secretion of a thin and normal mucus. Cases of fibri- 
nous bronchitis I have seen getting well in bath-rooms, the hot water 
being turned on for days in succession and the air thick with steam. 
An excellent inhalation in the inflammatory conditions of the respira- 
tory organs is that of ammonium muriate. Every hour, or at longer 
intervals, a gramme or more of the salt — the quantity depending in 
part on the size of the room — is burned on the stove or over a live 
coal or an alcohol-lamp. The heavy white cloud fills the room, is 
easily borne by both sick and well, and improves expectoration. 
Oil of turpentine can be utilized in a similar way. Its action is 
both expectorant and disinfectant. In the latter stages of pneu- 
monia, when the bronchial secretion is thick, viscid, or deficient, 
and expectoration and cough are wanting, the room may be filled 
with turpentine vapor. This can be accomplished in different ways. 
A large soft sponge may be soaked with turpentine, with or without 
the addition of some oil of sassafras, and suspended at the bedside. 
Or a kettle of water may be kept boiling day and night on the 
fireplace or over an alcohol-lamp (this is preferable to a gas-stove, 
which consumes too much oxygen), and a tablespoonful of turpentine, 
more or less, poured on the boiling water every hour or two hours. 
The same may be done to advantage in diphtheria, with or without 
a teaspoonful of carbolic acid in addition to the turpentine, and in 
gangrene of the lungs. The inhalation of benzine, cresolin, and 
similar substances, and of the coal-gas of gas-works, has often been 
recommended in whooping-cough. In its worst forms, particularly 
when it is complicated with convulsions, the frequent inhalation of 
chloroform is sometimes life-saving. A baby of six months, with 
hourly attacks of convulsions, I kept alive by putting him under the 
influence of chloroform at the beginning of every attack, and con- 
tinuing that treatment for several days. Asthmatic attacks will do 
well sometimes with inhalations of chloroform, ether, and spirits 
of turpentine in different proportions, mostly 1 to 2 to 4. Chloroform 
is well tolerated by the young, but should be avoided in the cases of 
lymphatic patients. Sudden deaths may be (and appear to have been) 
encountered in them, and may occur after weeks as a result of the 
parenchymatous changes in the heart caused or increased by the drug. 
Amyl nitrite also will influence them favorably; as a preventive 
of epileptic attacks I have experienced occasional success with its 
administration. But in collapse, with paralysis of peripheral blood- 



74 GENERAL THERAPEUTICS 

vessels, it certainly renders good service. With the inhalation of 
oxygen for the purpose of bridging over the most dangerous period 
of a suffocating pneumonia and of improving tissue-change in general 
anaemia and ill-nutrition, the profession is well acquainted. It is no 
use to deny that effect on theoretical grounds afforded by the alleged 
law of the diffusion of gases. If those who write books for prac- 
titioners would but study disease at the bedside ! With the inha- 
lation of ether as an antidote to poisoning with santonin I have 
no personal experience. Ozone inhalations have been highly recom- 
mended in anaemia, whooping-cough, and septic fevers. We shall have 
to learn more of its effects, and particularly in regard to a ready and 
reliable method of its preparation. A. Caille, while regretting the 
clumsiness and expensiveness of apparatuses, uses it in chlorosis, 
secondary anaemia, and whooping-cough. A personal communication 
of his speaks also of a case of tuberculosis in an adult successfully 
treated with ozone inhalations extending over several years. 

In pulmonary tuberculosis the inhalation of disinfectant vapors 
is employed less than the necessity of the cases would appear to 
indicate. Carbolic acid, turpentine, eucalyptol have been utilized for 
that purpose. The object is to supply the lungs with those substances 
in thin dilutions constantly. Prudden has proved that carbolic acid 
in twelve hundred parts of water stops the emigration of leuco- 
cytes in inflammatory disorders. Thus high dilutions, though they 
be hardly perceptible to the senses, and certainly not to a disagreeable 
extent, may be amply sufficient. It is for this reason that Feldbausch 
invented small apparatuses filled with a disinfectant substance to be 
persistently worn in a nostril. 

The inhalation of chloroform, which is, on account of the average 
vigor and healthiness of their hearts, preferable to ether for the pur- 
pose of producing anaesthesia in the cases of infants and children, is 
rather unsatisfactory at the earliest age because of the superficial char- 
acter of respiration. So is that of ether, which, moreover, may become 
contraindicated in every period of life because of its detrimental effect 
on the kidneys and on the respiratory organs. It frequently begets 
nephritis, which anyway is frequent in infancy and childhood, bron- 
chitis, and pneumonia. The effect of the anaesthetic is very tempo- 
rary, and the administration must be repeated and closely watched 
during a convulsion or an operation. The difficulty in obtaining a 
complete narcosis is particularly great in the newly-born. The stage 
of excitement is brief, the pulse becomes frequent, and the pupils 
contract. After a short time, however, the pulse becomes slow and 
the pupils dilate. The after-effects are not so inconvenient as they 



CHLOROFORM AND ETHER OPERATIONS 75 

often prove in the adult; infants and young children vomit less fre- 
quently and less profusely, and certainly with greater facility and 
ease than adults. They are liable to remain under the influence of 
the anaesthetic a long time after an operation has been completed. 
After tracheotomies, which I never performed without chloroform 
unless the children were asphyxiated by carbonic acid poisoning, the 
patients are apt to sleep long and undisturbed. Thus they require 
ceaseless watching until the effect has surely passed away. Through 
the opened trachea the children will get under the influence of chloro- 
form very easily. Five or six drops on a sponge or on some absorbent 
cotton, held in the mouth of the tube by means of a pair of pincers, 
have an almost instantaneous effect, and came near destroying — when 
I undertook to change the tracheal tube on the third day — a successful 
case of mine forty years ago, before I had the experience detailed 
in the previous remark. Further care is also required in regard to 
patients in ill health. Chronic pulmonary and heart diseases do not 
tolerate chloroform very well, but the diagnosis of these conditions is 
more readily and quickly made in children than in adults. Adipose 
children are liable to faint. The usual operations in the mouth, such 
as resection of tonsils, incision of abscesses, and evulsion of adenoids, 
it is best to perform without an anaesthetic, for the amount required 
to overcome the resistance of the masseter and buccinator is so large, 
generally, as to possibly endanger the life of the patients, besides the 
impossibility of obviating successfully the entrance of blood into 
the digestive organs, where it is inconvenient, or into the respiratory 
organs, where it is a positive danger. 

Of the two anaesthetics, ether and chloroform, the latter should, 
as a rule, be preferred in infancy and childhood, except in a case com- 
plicated with heart disease. It is the heart that runs its risk during 
the use of chloroform. The average vigorous young heart is less 
exposed to its dangers, but still its power of resistance should not 
be relied on too long. For several reasons operations should be per- 
formed quickly, though children are anaesthetized more readily than 
adults. For, after all, chloroform and ether are not indifferent 
agents, and may prove destructive ; the loss of a few ounces of blood 
is a serious matter, so long as a baby of thirty pounds has not over 
one and a half pounds at best ; and blood-pressure is diminished 
so long as the operation requires the uncovering of a large part of the 
surface. For every operation requiring an anaesthetic a saline solu- 
tion should be kept ready for subcutaneous injection. Among the 
disinfectants carbolic acid should not be used at all; even iodoform 
has occasionally proved dangerous. 



76 GENERAL THERAPEUTICS 

Gargles of any description require a certain degree of training 
and self-control, and are therefore rarely available for children of less 
than seven or eight years. The liquids thus employed do not reach 
any farther than to the uvula, the pillars of the soft palate, and the 
anterior part of the tonsils. Whatever succeeds in passing them is 
swallowed. Thus the alleged efficacy of gargles is greatly overesti- 
mated. Astringents, however, have a certain influence in reaching be- 
yond the area of contact, but through their secondary effect on con- 
tiguous tissue only. When a thorough effect is aimed at, it is better 
to rely on sprays, which may affect the whole pharyngeal cavity, or 
on insufflations of powders ; this latter plan is rather unpleasant, and 
should be followed in children in exceptional cases only. As, how- 
ever, in most cases where a local effect on the pharynx is desirable 
the local affection spreads over the posterior nares as well, spraying or 
(much better) irrigating the nose is preferable. The liquids thus em- 
ployed reach the pharynx, and are either swallowed — which is often 
an indifferent matter — or expelled through the mouth. When these 
methods are undesirable, — for instance, when the liquids injected 
enter the Eustachian tube, — they may be poured into the nasal cavities 
from a teaspoon or a pipette. A common medicine-dropper will sel- 
dom suffice ; one of the nasal cups for sale everywhere will do better. 
There is many a case of diphtheria in which the very gentlest method 
of cleansing and disinfecting the surface of the naso-pharyngeal 
cavity ought to be selected. More on this subject will be said in 
another part of this book (Chapter V.). 

When no liquids are tolerated, medicated ointments may be intro- 
duced into the nostrils by means of a camel's-hair brush, or poured 
in. Ointments prepared with vaseline, glycerin, or cold cream are 
good vehicles for that purpose. Sponges and brushes ought to be 
avoided whenever the young patient objects to them strenuously. No 
violence must be used for several reasons. The child's strength must 
not be exhausted by his attempts at self-defence, and most local 
affections of the throat get worse by any injury done to the epithelia. 
Even galvano-cauterization can and must be applied without much 
violence. Persuasion, patience, and cocaine will render its employ- 
ment possible in many instances. 

The skin in infancy and childhood participates in the anatomical 
structure of all the tissues at that early period, inasmuch as it con- 
tains more water than in advanced age. Besides, it is thinner, and 
its lymphatics are more numerous, larger, and more superficial. This 
explains some peculiarities in regard to the effects of many medica- 



GARGLES. THE SKIN. SINAPISMS. VESICATORIES 77 

ments. Hot air in apparatuses, as used by Tallerman and others, of 
140 C. and more, should be watched, and lower temperatures tried 
first. It is employed more in chronic than in acute ailments, arthritis 
of all forms, deformans and gonorrhceal included, muscular and other 
chronic rheumatisms, and the intense chronic muscular spasm of talipes 
valgus (very rare in children), also the progressive ossifying myositis, 
and chronic osteitis and periostitis. Electricity in all its forms is 
sometimes efficient, and a relatively mild current may suffice. This 
fact is of particular importance, as, moreover, the bones also are 
thinner and more succulent. To act upon the brain, very mild cur- 
rents only must be used. The spinal cord is less accessible, and 
appears to require rather large doses from large electrodes. The 
galvano-caustic effect resembles very much that obtained in the adult. 
In most cases it should be closely watched while being employed; 
thus, for instance, in the operation on angiomata, or diseases of the 
tonsils or nose, it readily destroys more than was intended. 

Sinapisms, when not mixed with flour, must not be permitted to 
remain more than a few minutes. As soon as the skin begins to be 
discolored they should be removed. When that is done, they may 
be repeated every few hours, and they are active derivants in many 
cases of deep-seated congestive processes. The same remark is due 
in reference to the use of mustard-baths. A hot mustard-bath ren- 
ders good services in suppressed or insufficient cutaneous eruptions 
of an acute character, internal hemorrhages, meningitis, and pneu- 
monia ; but it must not be continued beyond reddening the skin ; if 
so managed it may be repeated. 

Vesicatories have lost much of the esteem in which they were held 
in former times. I remember the time when many a case of pleurisy, 
articular inflammation, herpes zoster, was not permitted to get well 
without a Spanish-fly blister. Nor am I of the opinion to-day that 
it will do no good in some such cases, provided it be not used during 
the feverish stages. But their drawbacks are many. A plaster will 
not stick to an emaciated and uneven surface, and is even apt to give 
rise to gangrene when the surface circulation is very defective. In 
these cases the wound will heal badly. The skin of the infant being 
very vulnerable, eczema and impetigo will easily arise on ever so 
slight a provocation. The local pain of the application produces irri- 
tation, nervousness, and sleeplessness. This is particularly so if the 
application be made on the extremities or on the posterior surface 
of the body. The kidneys are frequently affected by cantharides, 
dysuria being the result in many cases, which then require energetic 
camphor treatment for the relief of the torturing symptoms. 



78 GENERAL THERAPEUTICS 

There are some absolute contraindications to the external use of 
cantharides : the presence of diphtheria in any shape or manner, and 
such diseases as are liable, during the prevalence of an epidemic, to 
become complicated with diphtheria. Therefore, no vesicatory must 
be used during nasal, pharyngeal, or laryngeal diphtheria (croup), 
or in the different forms of pharyngitis, or in laryngeal catarrh, or in 
erysipelas, or in diabetes. 

When a plaster cannot be expected to remain on the surface and 
to have its full effect, cantharidal collodion may take its place. The 
application will prove more effective when the surface is first washed 
with vinegar or irritated by a sinapism, which, however, is allowed 
to remain a few minutes only. Then a flaxseed poultice or warm-water 
applications may be applied over the vesicatory to diminish the pain 
and accelerate the effect. Very young infants ought not to carry a 
vesicatory more than an hour, at least not on the same spot. That 
is why to them the cantharidal collodion is less adapted. The plaster 
may be shifted from place to place. 

After the epidermis has been raised, the serum must be allowed 
to escape through small punctures, but not so as to moisten the adjoin- 
ing parts, for the cantharidin contained in the serum may exert a dis- 
agreeable local effect. The epidermis ought not to be removed, and 
no irritating ointment used to keep up a secretion. To cover the sore 
surface, vaseline or cold cream is preferable to common fats, which 
may be, or become, rancid. The best final dressing is borated cotton 
and a bandage. Vaseline ointments with opium, lead, or zinc, and 
powders of zinc, bismuth subgallate, iodoform and amylum in equal 
parts, or salicylic acid one part, with from thirty-five to fifty of starch, 
will find their occasional indications. 

In many affections of the skin powders, solutions, liniments, oint- 
ments, and baths are employed. The skin is thin and irritable. Ery- 
thema will follow the contact with water quite often; thus many 
forms of dermatitis contraindicate its frequent use. Acute and chronic 
eczema get on better without than with it. Therefore astringent solu- 
tions are less advisable than astringent ointments. For superficial 
effect these must be prepared with vaseline or cold cream, either of 
which may readily be combined with lead, tannin, zinc, bismuth, sali- 
cylic acid, or iodoform. In not a few cases, on a very sore surface, 
denuded of its epithelium and oozing, the powders alone, or combined 
with starch or talcum in different proportions, will prove very effec- 
tive. Oleates ought to be avoided ; they irritate the skin and pro- 
duce eruptions. ,.^ 

As the skin is thin and succulent, and the lymph-ducts of the young 



DEPLETIONS yg 

quite superficial, large, and numerous, substances will penetrate the 
skin quite readily. Ointments with that object in view must be pre- 
pared with animal fats, particularly with adeps lanae hydrosus of the 
United States Pharmacopoeia (lanolin), to the latter of which, when 
rather dry, ten per cent, of water may be added. Still, much friction 
may by itself irritate the surface and give rise to suffering. 

In the very young, ice and ice-water applications are not tolerated 
a long time. Ice to the cranium, the bones of which are but thin, 
is liable to produce collapse ; about the neck and occiput it is better 
borne and often beneficial. Warm fomentations and hot poultices are 
very beneficial in many morbid conditions of the trunk and extremities, 
but dangerous when applied to the head and not carefully watched. 
General baths are frequently required, local baths but seldom ; foot- 
baths may be given while the patient is lying down, but hot fomenta- 
tions are more readily made, and do not require the same amount 
of watching, nor are they equally objectionable to the young patient. 

Depletions were frequently resorted to scores of years ago. Mod- 
ern practice has learned how to do without them, though we should 
be willing to assume that they were more frequently indicated than 
many of us believe at present. At all events, it ought to be taken 
into consideration that there is but a single pound of blood in a baby 
of twenty pounds, and that a patient rapidly reduced by sickness is 
least able to stand a loss of blood ever so small. Thus a venesection 
will hardly ever be thought of in the case of a baby ; at all events, I hope 
never to repeat the opening of a jugular vein, practised by me on 
an infant taken with convulsions depending on, and adding to, cere- 
bral congestion, forty years ago. But there are cases of older children 
that bear, or rather demand, a venesection. Its indications are over- 
extension and insufficiency of the (mostly the right) heart with im- 
peded pulmonary circulation, with intense dyspnoea and cyanosis, in 
which the largest doses of digitalis have been given in vain. In one 
of his cases Baginsky opened the radial artery when he did not 
succeed in getting blood from a vein. Such cases are occasionally 
pulmonary oedema during the incipiency of the crisis in a croupous 
pneumonia, or, principally, old mitral incompetencies with immense 
dilatation and failing compensation. The objects to be accomplished 
are the relief of the feeble heart muscle and the restoration of its con- 
tractility. A further indication for a venesection may be afforded in 
occasional cases of uraemia or eclampsia, similarly to its employment 
in the adult. Local depletions were once more frequent, though the 
liability of the skin to^tnflammation and furuncle was well understood, 



8o GENERAL THERAPEUTICS 

and the excitement of the little patient was such, now and then, as 
to lead to an increase of the symptoms and even to convulsions. 
Among the occasional drawbacks was also the possible loss of blood 
after the leeches had fallen off. In such a case the local use of tannic 
acid, alum, perchloride or subsulphate of iron, digital pressure, or in 
bad cases the ligature underneath a harelip needle, which was inserted 
through the wound, were resorted to. A solution of from twenty 
to fifty per cent, of antipyrin in water, which may be immediately 
followed by a solution of tannic acid (mostly not required), is a 
powerful styptic. The indications for depletion were bad and painful 
cases of pleurisy and peritonitis, and cerebral inflammatory diseases. 
In the two former, the indication to relieve pain is more readily fulfilled 
by ice or the subcutaneous use of morphine or cocaine. In the latter, 
the mastoid process and the septum narium are the points on which 
the leech or leeches ought to be applied. It is the latter spot which 
I prefer, when I have the choice, in those rare cases of brain diseases 
of infants and children in which I still feel justified in recommending 
a depletion. Altogether, however, many of the olden-times indications 
for bloodletting have proved deceptive. It does not serve as an anti- 
phlogistic in all sorts of fevers and inflammations, or as an evacuant 
of an alleged plethora, or as a sedative and anaesthetic, but it cer- 
tainly may be employed to divert a local stasis, even in cases in 
which apoplexy is feared. In toxic conditions, particularly in intense 
sepsis, it should be carefully avoided, though acute poisoning may 
be relieved by it. Uraemia, or carbon oxide poisoning, may, as I said, 
be benefited by a venesection, and the diminished circulating medium 
replaced by a saline solution administered either subcutaneously or 
injected in the rectum or directly into a vein. 



Ill 

Treatment of the Newly- Born 

I. Asphyxia. 

The prognosis of asphyxia and of its treatment is a very doubtful 
one in many cases. It depends not only on the knowledge and skill 
of the physician, but on the causes of the abnormal condition. A 
moderate or serious compression of the head, compression or pro- 
lapse of the cord, intra-uterine respiration and aspiration of foreign 
bodies (amniotic liquor, meconium), apoplexy, anaemia of the fcetus, 
accumulation of carbonic acid in the blood, poisoning by morphine 
or chloral, taken by the mother, or by her excessive temperature, con- 
genital diseases, and malformations, each of them, or several com- 
bined, influence both the prognosis of the individual case and the 
result of therapeutic procedures. 

When the long duration of labor, the prolapse of the cord, the 
protracted compression of the head, the early loss of amniotic liquor, 
placenta prsevia, or a high temperature of the mother endangers the 
life of the fcetus, the best preventive of asphyxia is the artificial ter- 
mination of parturition. The respiratory organs of the fcetus pass- 
ing out of the vagina should be protected from contact with copious 
discharges of liquor amnii and other foreign material accumulated 
in the bed, and the face be raised so that aspiration, mostly through 
the nose, cannot take place. The mouth of the newly-born, unless 
it cries lustily, must be cleansed immediately, but very gently, by a 
moistened piece of cloth wrapped round the finger, the tongue drawn 
forward, and the baby placed on its side before attention is paid to 
anything else. Beating the nates, tickling of the fauces by means of 
the feather of a hen or a goose, and the momentary inhalation of am- 
monia can be resorted to before the baby is separated from the pla- 
centa. Most practitioners, indeed, will, under the usual circumstances, 
prefer to prolong the connection with the maternal organ until the 
pulsation of the cord begins to flag. The separation of the baby 
must take place immediately when there is no pulsation in the cord 
or when asphyxia is well pronounced. When the baby is strong and 
cyanosis marked, Grenser recommended to allow the cord to bleed 
before the application of the ligature. When bleeding was scanty, 

6 81 



82 TREATMENT OF THE NEWLY-BORN 

he increased it by placing the baby in a warm bath. This procedure 
I have imitated several times with advantage. 

When the ligature has been applied and the baby removed, the 
mouth of the asphyctic infant ought to be cleansed again as above, 
quickly but gently. For amniotic liquor, meconium, and vaginal 
secretion, when aspirated, will, though the asphyctic condition may 
be relieved, give rise to bronchitis and pneumonia after two or four 
days. Many babies die in this way. 

Insufflation into the lungs for the purpose of establishing respi- 
ration was practised by Smellie as early as 1762. It is done from 
mouth to mouth, from mouth to nose, or through a catheter intro- 
duced into the larynx. The first method is not reliable, for the tongue 
is liable to close both pharynx and larynx ; the second is often success- 
ful, but may inflate the stomach as well as the lungs. By inflating 
the former the chances for a normal action of the lungs become less. 
After every insufflation which fills the lungs, the chest ought to be 
compressed by two hands over the lower latero-anterior region of 
the chest-walls to facilitate expiration. 

The direct insufflation of the lungs may become detrimental for 
several reasons. H. Reich relates the case of a consumptive midwife 
who was reported to have infected twelve infants with acute tuber- 
culosis in thirteen months. In the practice of another midwife, who 
was healthy, in the same town, no such case occurred. During 
nine previous years there were but two cases of tubercular meningitis, 
and but one in the year following the death of the consumptive woman. 
Moreover, the act of insufflation may prove dangerous by the im- 
possibility of limiting the force of the entering volume of gas. Rup- 
ture of pulmonary tissue and emphysema and pneumothorax have 
been observed. The same accident may occur when a catheter is 
used for the same purpose. It has, however, the advantage of per- 
mitting the sucking out of the aspirated material before air is blown 
into the lungs. Ribemont's and other metal catheters cannot be 
carried much below the vocal cords. An elastic catheter, guided by 
a wire which allows any degree of bending and may be withdrawn 
when the vocal cords have been passed, is better adapted both for 
aspiration and inflation. 

The asphyctic baby ought to be plunged into a warm bath (ioo° 
F.) immediately and gently rubbed. The other methods may be 
continued during that time, — beating, tickling, electricity. When it 
is thin, pale, and collapsed, a hot injection into the bowels (from 104 
to 1 1 5 F.) will render good service. The quick and repeated alterna- 
tion between the warm bath of a minute and a cold one of one or 



ASPHYXIA 33 

two seconds, or the pouring of cold water on chest or neck while the 
body is in the warm bath, restores many ; but great care must be 
taken lest the latter be too hot. It may produce clonic or tonic con- 
vulsions, and has been reported as giving rise to tetanus. Before 
and after the bath, indeed at any time, the vigorous swinging of 
the baby on the arms of the medical man is a good adjuvant. 

Among all the mechanical methods of artificial respiration (Mar- 
shall Hall, Silvester, Howard, B. Schultze, Pacini, Woihler, Bani, 
Schuller, Dew, and others) those of Silvester and Schultze render 
the best services in the asphyxia of the newly-born. Both are very 
simple, and either of them is effective. A. Brothers prefers the 
former (" Infantile Mortality during Childbirth and its Prevention," 
Philadelphia, 1896). 

Silvester places the patient on his back, a small pillow (piece 
of clothing, towel, sheet) between the shoulders, the tongue drawn 
forward. The two arms are caught above the elbow and while 
being everted are slowly carried upward. Thus the chest is expanded. 
Then they are carried downward and pressed against the sides of 
the chest, a little anteriorly to the axillary line. Thus the lungs are 
compressed. This combined action may be repeated fifteen or twenty 
times in a minute, and a hot bath given afterwards. Then the pro- 
cedure is renewed. 

B. Schultze places his index-fingers in the axillae, the three other 
fingers gently against the sides of the chest, the thumbs covering 
the shoulder from behind. The infant is then swung forward. The 
lower extremities bend on the abdomen, the abdomen presses against 
the diaphragm, and the lungs are compressed, — expiration. The 
parts then return slowly downward and swing back, thus expanding 
the chest, — inspiration. This action may also be repeated fifteen or 
twenty times in a minute. After each minute's swinging the baby 
is placed in a warm bath. There is but one (occasional) contraindi- 
cation to the employment of this method, — viz., the insufficient devel- 
opment of the fcetal bones. When the newly-born is too premature 
and the ribs too soft and flexible, it is useless. It is also contra- 
indicated in the plethoric, congestive variety of asphyxia. That 
proper caution should be exercised is self-understood. In a case 
published in the London Lancet of May 8, 1897, the infraspinatus 
and teres minor muscles were injured so as to cause rotation and 
adduction of one arm. 

During all this time, whenever feasible, the surface of the infant 
must be kept warm artificially by hot blankets, stones, bottles, and 
a few drops of brandy, whiskey, camphor-water, or tincture of musk, 



84 TREATMENT OF THE NEWLY-BORN 

or a drop of tincture of belladonna may be given in some hot water 
if deglutition is possible, or a larger quantity (some ounces) of hot 
water (from 104 to 115 F.) injected into the rectum. When the 
main difficulty appears to be, after a while, in the excessive debility 
of the heart, with absence of the radial pulse, a five-hundredth part 
of a grain of nitroglycerin, repeated after fifteen and thirty minutes, 
may render good and speedy service through its ready absorbability 
on every mucous membrane. I have no experience with it in the 
asphyxia of the newly-born, but its rapid action in failing heart 
and collapse and shock from other causes encourages me to recom- 
mend it for a fair trial of its powers. 

Laborde was very successful by drawing the tongue of the asphyc- 
tic baby forward in rhythmical alternations. That procedure is to 
be repeated ten or fifteen times a minute. It does not seem to be 
promising unless the reflex irritability (small in the normal new-born) 
of the medulla oblongata is rather intact. 

Electricity was recommended in cases of asphyxia as early as 
1793 by Huf eland. But the first case in which the rhythmical fara- 
dization of the phrenic nerve and its associates was resorted to (Ziems- 
sen) for the purpose of producing artificial respiration was that of 
an asphyctic girl poisoned by carbon oxide. The phrenic nerve 
acts on the diaphragm. Its aids are the cervical plexus, which con- 
trols the trapezius, levator scapulae, and middle scalenus muscles, 
and the brachial plexus. The ramifications of the latter are the ante- 
rior thoracic nerve for the pectoralis major and minor ; the posterior 
thoracic for the middle scalenus, posterior superior serratus, and the 
rhomboid muscles ; and the lateral thoracic for the serratus anticus 
major. 

In many cases since, such as poisoning by chloroform, coal-gas, 
opium, diphtheria, hydrogen sulphide, and pernicious intermittent 
fever, also in those of apoplexy, drowning, and hanging, electricity 
has been employed to advantage. Its effect is often rapid and 
powerful. 

In asphyxia of the newly-born, the systematic faradization of 
the phrenic nerve was first employed by Lauth and Pernice. 

The point of application selected by most authors is near the 
sterno-cleido-mastoid muscle, over the phrenic nerve. The other pole 
is applied either to the neck or to the diaphragmatic region or any 
other part of the surface. The localization of the effect to the phrenic 
nerve alone, which was insisted upon by many, is certainly an illusion. 
The current will surely strike the pneumogastric, phrenic, sympathetic, 
and manv sensitive and motorv nerves at the same time. As this 



ASPHYXIA 85 

cannot be avoided, as indeed it is better that it should be exactly so, 
it is best to use large sponge electrodes and moisten them thoroughly 
with salt water. The head, arms, and shoulders should be slightly 
raised, and a small pillow placed between the shoulders for the asphyc- 
tic baby to rest on. One of the electrodes must be kept stationary, 
the other brought into contact with the surface a single moment only. 
A deep inspiration will then take place, the lungs will expand, and 
lateral pressure on the lower part of the chest should be resorted to 
for the purpose of emptying the lungs afterwards. Another applica- 
tion is then made with the same result, and must be followed by 
the same manipulation. This has to be continued for some time until 
the baby cries, and until it appears safe to discontinue the application. 
Whenever a cough or a coughing movement is noticed, it should be 
omitted temporarily. The favorable result, however, is not always 
permanent. The causes of the asphyctic conditions are still active, 
and the infant will require resuscitation again, and perhaps many 
times. Thus close attention must be paid, sometimes for hours. 

Great care should be taken in regard to the duration of the appli- 
cation. Continued or too frequent irritation by the current causes 
over-irritation and paralysis. Not infrequently the immediate effect is 
a favorable one, inspiration becoming deep and the heart active, but 
after a short time the former grows more superficial, the pulse feeble, 
and the cyanotic hue returns to the lips and finger-nails. Then it 
is time to stop for a while, and resort temporarily to other means 
of resuscitation. Thus the practice of Lauth, who applied the cur- 
rent persistently for two or three minutes, is decidedly improper 
and dangerous. 

In some cases, where the interrupted current is inefficient, the 
galvanic (continuous) current, with occasional reversions, has been 
known to yield better results. In my own cases I have never had an 
opportunity or been under the necessity of employing it. 

The application of large sponge electrodes may not always be 
convenient. In those cases no harm is done by using the metal poles 
instead. Though the irritability of the brain (and nerves) is low 
in the newly-born, the pain produced by the interrupted current 
thus applied is very intense, and the effect on the contraction of 
the diaphragm quite marked. Thus it is not necessary to lose time 
in preparing, if it be not on hand, the more complicated apparatus. 
Still, exhaustion is more readily obtained through resuscitating by 
pain and muscular action combined than by muscular contraction 
alone. In most cases, however, I was satisfied with not losing 
evea a fraction of a minute, particularly in those early times, when 



86 TREATMENT OF THE NEWLY-BORN 

the most convenient apparatus was the old-fashioned rotating ma- 
chine. 

How long is the asphyctic baby to be watched and the attempts 
at resuscitation to be renewed ? At all events, they must not be given 
up so long as the heart-beats are audible, though ever so feebly. Nor 
is a single scream sufficient to permit watchfulness to be relaxed. 
The deep recession, during inspiration, of the diaphragmatic region 
(the " peripulmonary groove 1 ' of Trousseau) should have ceased, the 
cry be vigorous, the eyes wide awake, and the extremities in lively 
motion. Before this is accomplished there is danger of a relapse, 
partly from impaired innervation and the continuation of some of 
the causes of asphyxia, and partly from obstruction through mucus, 
which may be coming up constantly and gather in the pharynx and 
posterior nares. 

Some cases of asphyxia are particularly troublesome: those in 
which it is due to prematurity of the newly-born or to an actual 
anatomical change (hemorrhage, compression of the brain or me- 
dulla) which requires time to get well or will terminate fatally ; also 
those which are due to congenital anomalies of the organs of circu- 
lation or respiration (syphilis of the lungs, effusion into the pleural 
or the peritoneal cavity, thoracic tumors, etc.). 

' There is no more trying hour in the life of the practitioner than 
that spent on resuscitating an asphyctic newly-born. Every moment 
tells. For it is on the immediate restoration to full life that will 
depend the narrow border line between a physically and intellectually 
normal human being and an epileptic, paralytic, or idiotic invalid. 
That is why I placed asphyxia at the head of this chapter and em- 
phasized its many dangers and possible sources of relief. 



2. Postnatal Asphyxia and Atelectasis. 

Atelectasis may be congenital or acquired. The lungs may never 
have expanded to their normal degree, or after expansion had taken 
place, they may have collapsed or contracted again. The causes of 
this condition may also be either congenital or acquired. There may 
be malformations and intra-uterine diseases of the organs of respira- 
tion or circulation, such as defective development of the lungs, hernia 
of the diaphragm, hypertrophy of the thyroid gland, pleural effusions, 
syphiloma of the lungs, acquired bronchial catarrh, bronchitis, and 
pneumonia. Or anomalies of the nervous system may exist, such as 
hemorrhage or some other injury of the respiratory centre, and cere- 
bral pressure from effusion, besides intra-uterine malformations. Or, 



ATELECTASIS. IMMATURITY. PREMATURITY 87 

finally, the baby may be premature, with feeble muscles and soft 
bones. 

The treatment resembles much, or is identical with, that of genu- 
ine asphyxia. Respiration must be insisted upon. Warm and cold 
baths, cold affusions in the warm bath, swinging, beating, and elec- 
tricity each come in for their share in the treatment. The baby must 
be made to cry, or it will perish. This indication is particularly urgent 
in the acquired cases of atelectasis which result from bronchitis. 
There the small bronchial tubes are filled with a viscid sticky mucus, 
which must be removed. This is a condition not peculiar to the quite 
young only; it is as well met with in older babies suffering from 
bronchitis, particularly when in a condition of ill-nutrition and general 
debility. In them, the closing of the nose and mouth for from four 
to eight seconds will so saturate the respiratory centre with carbonic 
acid as to elicit deep and forcible inspiration through irritation of 
the medulla. It is an effective method, and not cruel because it is 
successful. 

The babies should be fed conscientiously. (See Chapter I.) As 
many are suffering from inanition, this requires close attention. They 
should have plenty of water, warm or hot, with from one to four 
drachms of brandy through the twenty-four hours, aqua camphorae, 
a few drachms ; perhaps, as suggested above, nitroglycerin. Hot 
injections of saline solution into the rectum will stimulate the nerves 
and fill the blood-vessels. The infant must be carried about, its 
position in bed changed from time to time, and its skin kept warm 
according to the methods detailed above. Even the most desperate- 
looking cases, with shallow respiration and cyanosis of the skin and 
mucous membranes, may recover when the attendants are as persistent 
as the morbid condition is dangerous. 

3. Immaturity and Prematurity. 
Immature (born before the twenty-eighth week) and premature 
babies (born between the twenty-eighth and thirty-eighth weeks) re- 
quire a great deal of care, the more so as their condition may be con- 
nected with a low state of the mother's nutrition or with an inherited 
illness (syphilis). Those which are not really diseased, but merely 
undeveloped, with low weight, wrinkled, covered with lanugo, cyanotic, 
sometimes exhibiting sclerema, demand the most scrupulous hygiene 
and diet. It is in this condition that Crede's, Winckel's, and Tarnier's 
apparatuses (couveuse) have triumphed over great difficulties. The ap- 
paratus of Dr. L. Emmett Holt is simple, practical, and inexpensive. 
A large metal incubator, devised by Mr. John P. Putnam and Dr. 



88 TREATMENT OF THE NEWLY-BORN 

Rotch, of Boston, in which the baby lies upon a water-bath and is 
heated by graduation from all sides, was described by Dr. TL D. Chapin 
in Archives of Pediatrics, May, 1897. Still, any box or bed, with hot 
bottles and stones, or a box with double walls filled in with hot sand, 
or a bed with hot flannel or cotton, or carefully exposed to the hot 
register, or anything the good-will and ingenuity of the practitioner 
may supply, will answer the purpose. At the same time the air ad- 
mitted to the lungs should be moderate (70 F.) and pure, the ventila- 
tion of the room should be indirect, there must be no draught, the 
washing — with warm water, no bathing — should be done quickly, and 
the skin dried with the softest of materials. Any carelessness may 
lead to asphyxia, atelectasis, and sepsis. This may enter through any 
sore on the integument or through the umbilicus ; for in this condi- 
tion the cord is more liable to rot than to mummify. Besides, there is 
usually a large quantity of uric acid infarction, with the tendency 
to retention of urine and uraemia. That is why as large a quantity 
of water is required as can safely be introduced. Altogether, feeding 
is difficult, no sucking is possible, the teaspoon or a medicine-dropper 
should be employed at short intervals. Besides peptonized milk and 
water (1 to 8 or 10), sugar-water, moderate stimulants, a few drops of 
whiskey in water hourly, and warm saline enemata should be given. 
Gradual changes will suggest themselves to the medical attendant. 

In this way, of babies weighing from one thousand to fifteen hun- 
dred grammes fifty per cent., of those weighing from fifteen hundred 
to twenty-five hundred grammes from seventy to ninety per cent, 
have been saved. D'Outrepont saved a newly-born of thirteen 
inches in length and one and a half pounds in weight, Kopp one of 
eleven inches and two pounds, Redman one of thirteen inches and a 
pound and three and a half ounces, Ahlfeld one that was born in the 
twenty-ninth week of utero-gestation, measured fifteen inches (thirty- 
nine and a half centimetres), and learned how to suck after a few 
weeks; and another one of the same size and a weight of forty-eight 
ounces (fourteen hundred and fifty grammes) when five weeks old. 
It also took the breast afterwards. Several infants of less than three 
pounds at birth I have saved myself, nor are similar cases very rare 
in the literature of the subject. 

J. H. Moore published in the Philadelphia Reporter of April 17, 
1880, the case of a foetus born before the end of the sixth month of 
utero-gestation — length nine inches, weight one and a half pounds — 
that cried after thirty minutes, but did not move. Fifteen months 
afterwards the same " foetus" is said to have commenced to walk, 
and to have weighed nineteen pounds. 



KEPHALH/EMATOMA 89 

4. KcphalJhcmatoma. 

The hemorrhage between (mostly) the parietal, rarely the oc- 
cipital, and still more rarely the frontal bone and its pericranium 
is usually the result of pressure by the lower segment of the uterus, 
not always during protracted labor, or by the forceps, for occasionally 
kephalhaematoma is observed after breech presentation also. Pre- 
disposition is caused by the deficient development of the external 
layer of the cranial bones and the shallowness of the indentations in 
which the blood-vessels are running, the thinness of the vessels, and 
the mobility of the integument, caused by the loose and vascular 
structure of the connective tissue of the pericranium. It is circum- 
scribed, does not spread beyond a suture, fluctuates, and begins, after 
a few days, to be surrounded by an osseous ring, the result of the 
formation of new bone from the raised periosteum. It grows in size 
for some days, then remains stationary, and is absorbed within from 
six to twenty weeks. After this time the bone is thickened, but 
absorption of the newly formed osseous tissue will take place in most 
instances. In exceptional cases only a permanent thickening will be 
noticed in later life. 

In some cases there is an internal kephalhaematoma as well. It 
consists in bleeding between dura mater and cranium, and may lead 
to all the consequences of intracranial hemorrhage (apoplexy of the 
newly-born), — viz., convulsions, paralysis, death, or meningitis, cystic 
degeneration, etc. There may be no contiguity between the external 
and the internal hematoma. Still, many cases of the external form 
will extend directly into the cranial cavity through a congenital (trau- 
matic) fissure in the bone. 

The treatment is forestalled by what has been said of the spon- 
taneous absorption of the extravasation. No treatment is required. 
The swelling must be left alone. The bony thickening will also get 
well in the course of time. It is important to insist upon this expec- 
tant treatment, because the attendants will often not appreciate the 
absolutely benign nature of the large tumor. 

Meddlesome practitioners have tried compression. If there be 
any communication with the cranial cavity, this procedure may be- 
come dangerous by blood being forced into the interior. Ointments 
have been recommended " to make believe," for the purpose of quiet- 
ing the anxiety of the family. Puncture has been resorted to. If 
made at an early period, it will facilitate new bleeding; in many a 
case it has been known to produce suppuration, though the operation 
was believed to have been aseptic. Incision is still more reprehensible. 



90 



TREATMENT OF THE NEWLY-BORN 



It is not permissible except in those cases which have terminated in 
suppuration through previous maltreatment or septic infection. Then 
a large incision and thorough disinfection are indicated, and will be 
followed by relief from pain, redness, and fever. Puncture, aspira- 
tion, or incision may perhaps be necessary, even without suppuration, 
in one of two conditions : first, the tumor may be so large as not to 
undergo absorption for many weeks, and to endanger the bone, which 
may become necrotic; still, I have not seen such a case these twenty 
years ; secondly, in a case of complication with apoplexy, aspiration 
may be capable of allowing some of the internal extravasation to 
escape. 

Other indications for the treatment of this internal kephalhsema- 
toma are suggested by asphyxia or other symptoms which depend on 
disturbed innervation. The antiphlogistic treatment will be confined 
to cold or cool applications only. The consecutive paralysis demands 
an appropriate treatment, the results of which will be mostly question- 
able, and depend upon the amount of extravasated blood, of tissue 
destroyed or compressed, and consecutive changes in the nerve-centres. 
Surgical interference, particularly when there is depression of bone, 
was recommended by Jenkins, who reported a successful case. When 
there are positive symptoms of compression of the brain, it is safe 
to presume that the internal hematoma corresponds in its location 
with the external one. A fatal prognosis would justify surgical 
interference. 

5. Hematoma of the Stemo-Cleido-Mastoid Muscle. 

The fragility of the fcetal blood-vessels and an injury experienced 
by the muscle during parturition give rise to a hemorrhage about or 
above, seldom below, the middle part of the long muscle. When 
observed, the tumor has the size of a hazel-nut or larger ; it is spheri- 
cal, circumscribed, and rather hard. The latter condition is due to 
the secondary inflammation of the torn muscular fibres. This occur- 
rence is not very uncommon. Even in older children, mainly in kite- 
flying boys, who suddenly strain either of their sterno-cleido-mastoid 
muscles, the same hematoma and myositis are observed. 

When observed at an early period the local application of ice 
may reduce the bleeding, though the blood of the newly-born is not 
coagulable like that of more advanced age. For a week, after ceasing 
the employment of ice, small pieces of cloth moistened with cold 
water will check the secondary inflammation to a certain extent. Very 
gentle massage should be employed after the disappearance of the 
severe pain of acute inflammation. During all this time the head 



HEMATOMA. SCLEREMA 91 

must be kept immovable, — best perhaps by carrying the baby on a 
hair pillow large enough to support the whole body, head included. 
When the tumor has time to become hard, it may last for years; 
when it is large, it may give rise to torticollis. Then gentle stretching 
and massage, the application of a mild galvanic current, and the 
inunction of an absorbable ointment of potassium iodide may be 
tried to advantage (iodid. potass., aq., aa 1; adep., 2; adep. lanse 
hydros., 6 to 8). If torticollis ensue in later life, surgical treatment 
will be required (not necessarily the knife). 

6. Sclerema. 

The induration of the connective tissue of the newly-born known 
by that name consists of a serous infiltration of, and under, the skin, 
also of the muscles, begins generally in the lower extremities, and 
spreads over the whole body with (mostly) the exception of the 
chest. The surface is apt to be slightly hypersemic in the beginning, 
and then turns yellowish and quite pale. Respiration is shallow, 
nursing feeble, secretion of meconium and urine scanty, sensibility 
diminished, the pulse slow (60 to 75), accelerated only towards the 
fatal end, and temperature reduced much below the normal, even to 
90 F. and less. Recovery very rarely takes place. Even those 
who suffer from a slight attack only are liable to perish of pneu- 
monia or of nephritis after two or three weeks. Many of the infants 
are prematurely born, exhibit defective innervation, possibly resulting 
from fcetal brain disease, or suffer from some cardiac affection, 
myocarditis or other. No infectious invasion can be traced as yet. 
The fat of the newly-born contains only 43.3 per cent, of oleic acid 
compared with that of the end of the first year and later, when it 
has sixty-five per cent. The badly nourished infant has still less oleic 
acid than mentioned, and in them the peculiar stiffness of the body, 
mostly beginning in the calves of the legs (there is more oleic acid 
in the fat round the os calcis), depends on that condition of their fat. 

The patient must be fed from a spoon or dropper and by the 
rectum. Feeding is, however, very difficult. Food should be warm, 
rectal injections hot. Alcoholic stimulants may be given in the shape 
of brandy or whiskey, four or six drops every half-hour ; also a drop 
of tincture of digitalis every hour or two hours, and aqua camphorae, 
ten drops every hour. Massage with oil or lanolin, commencing at the 
periphery, gentle but persistent with the thoroughly warmed hand 
or through a warmed cloth, will improve circulation and probably, 
to a certain extent, absorption. Maybe, also, passive movements, 
practised gently but persistently, and extensive (general) galvaniza- 



9 2 TREATMENT OF THE NEWLY-BORN 

tion of the surface will serve the same purpose. The infant must 
be kept warm near a stove or furnace register, provided the head 
can be kept away from it and the air-supply for the lungs be kept 
up at a moderate temperature. Otherwise hot stones, hot sand, hot 
bottles must be distributed, well covered, through the bed at a safe 
distance. Frequent bathing in salt water of at least ioo° F., with 
constant friction and massage in the bath, will prove as beneficial 
as the bad or very doubtful prognosis will permit. 

7. Bathing. 

The first bath of the newly-born, and bathing of infants in general, 
demand great caution ; for the temperature of the young has its 
peculiarities. After having been higher in the foetus while in the 
uterus than that of the mother, it is apt to lose a degree (F.) or 
more, immediately after birth, in consequence of defective circulation 
and respiration and of the great difference in the baby's surroundings 
before and after birth. A feeble new-born requires more time before 
its temperature rises again to a normal standard. That is particularly 
so in regard to the skin. Thus it is that the thermometric measure- 
ments when made in the axilla are as deceptive in the feeble young 
as they are apt to be in adipose adults, with their insufficient super- 
ficial circulation. 

To a certain degree the cool air of the room has a tendency to 
reduce the surface temperature of the newly-born. When moderate, 
the sudden change acts favorably by inciting reflex action, but a 
considerable and continued reduction of temperature must have a 
dangerous influence at a time when the functions of the body are not 
yet regulated. 

In Lassar's experiments,* when an animal, after recovering from 
albuminuria, was exposed to a cold temperature, the same condition 
returned. Rabbits thus exposed, without or after depilation, suffered 
from interstitial inflammations of the liver, the lungs, the heart, and 
the neuroglia. The blood-vessels of the liver and the lungs became 
enormously dilated, the arteries filled with thrombotic masses, and 
leucocyte emigration was marked round the smallest veins. When 

* Virchow's Arch., vol. lxxix. A large amount of literature on the same 
subject has been since collected by Reineboth in vol. lxii. of Deutsche Archiv f. 
klin. Med., 1898. By sudden cooling he caused suggillations of the pleura, also 
disintegration of the blood ( hemoglobinuria), thereby irritation of the vaso- 
motor centre, with bursting of the finest pleural and pulmonary blood-vessels, 
though there was no reason to assume a greater fragility on the part of the 
blood-vessel walls. 



BATHING 93 

the animal was pregnant, even the liver and other organs of the foetus 
were found to be inflamed. This is exactly what clinical experience 
has taught every observer of every generation, in spite of modern 
contradiction. Thus I have observed a sudden return of the morbid 
symptoms in a number of persistent and protracted cases of haemo- 
globinuria after every exposure to cold, and particularly to cold and 
moist air. 

Therefore the newly-born babe should not remain uncovered for 
any length of time. The nurses who spend — with more pedantry, em- 
phasis, and self-consciousness than intelligence — much unnecessary 
time in oiling and soaping and washing and bathing, turning this 
and that way, drying the surface, wrapping the navel, applying the 
bandage, and dressing the newly-born in fineries, in which it finally 
returns to its mother's bed or to its crib shivering with a cold nose 
and blue feet, are not infrequently the causes of ill health or death. 
In a case recently seen, the pneumonia of the newly-born was un- 
doubtedly due to the fact that the baby was neglected while both physi- 
cian and nurse were engaged about the fainting mother. Craig must 
have seen many such cases, for with him " no baby is ever washed, 
dressed, fed, tied up, the cord is not wrapped up, but the infant is 
anointed with fat and wrapped in flannel the first twenty-four or 
thirty-six hours." Similar advice has been given repeatedly. 

The bath of the newly-born must not be hot. A single midwife 
in Elbing lost ninety-nine babies out of three hundred and eighty, of 
trismus. Through all her life she had estimated the temperature 
of the bath by trying it with her uncovered arm. She lost her tem- 
perature sense after a while, as was found by a judicial investigation, 
and the babies their lives. Still, the bath ought not to be less than 
90 ° F., nor ought it to be much cooler through a number of months, 
in spite of a French author's opinion, who says that the epidermis 
becomes macerated by warm baths ; that babies who are bathed grow 
" pale, soft, and flabby and eczematous," and proves the correctness 
of his position by his zoological discovery that " no other mammalia 
take a warm bath regularly." * 

* To the general rule implied in the above remarks on the necessity of 
bathing in warm water only, according to which the body of the newly-born 
infant is to be kept warm, the head forms an exception. Artificial heat and 
feather pillows ought to be avoided. A soft hair pillow is preferable, or a 
quilt lined with a layer of cotton. Whenever it is necessary to employ a 
soft head-rest, a feather pillow may be covered by a bed-sheet folded to the 
size of the pillow and fastened to its corners by safety-pins. Air-cushions 
ought to be in more common use than they are. 



94 TREATMENT OF THE NEWLY-BORN 

The proportion of the surface to the cubic mass of the human 
body is larger in an infant than in an adult, and the number of 
peripheral nerve-ends and capillaries relatively larger. Thus, there 
is a greater liability to reflex symptoms depending on exposure, in 
spite of the low degree of nervous irritability in the newly-born during 
the first few weeks. That is why a protracted cold bath is not well 
tolerated even by older infants ; but, also, why tepid or cold bathing 
or packing exhibits a very much more rapid effect in the young than 
in the old. For both the reduction of temperature and the reflex 
effect do not depend on the weight of the body, but on the extent 
of the conducting and radiating surface. 

While the cord is drying, and until it has fallen off, it is better 
not to bathe the newly-born again after its first bath. Washing may 
take its place, for it is best not to interfere with the normal drying 
process. 

When the baby is six months old, particularly during the summer 
months, the warm bath is to be succeeded by washing and friction 
with tepid and, later on, with cold water. When washing is sub- 
stituted for bathing, water may be selected of a lower temperature, 
inasmuch as but a part of the surface is exposed to its influence at 
one time. When the bath, in the course of time, is gradually made 
cooler, friction of the skin during bathing stimulates its action. In 
pathological conditions, when cool or cold bathing is resorted to for 
the purpose of reducing an abnormal temperature, this aim is always 
and easily reached so far as the surface is concerned ; but, to accom- 
plish the same end for the whole body, it is necessary that the skin 
should retain its vitality and lively circulation. Unless that be so, the 
internal temperature may remain unchanged or even rise while the 
surface is cool. In such a case, which must be ascertained by taking 
the rectal temperature, the cold bath ought to be followed immediately 
by a hot one for the purpose of restoring the surface circulation. In 
this way the reduction of temperature aimed at by the administration 
of a cold bath may finally be accomplished by hot water. In- less 
urgent cases the warming of the extremities and of the general sur- 
face by dry heat may suffice to restore the warmth of the surface. 
At all events, a cool or cold bath, after which the feet do not become 
warm at once, is dangerous. 



8. Mamma. Mastitis. Perimastitis. Angioma. 

Since the time of Menard, Scanzoni, and Guillot, the secretion of 
the mammary gland of the newly-born has been the subject of fre- 



MAMMA. MASTITIS. ANGIOMA 95 

quent investigations by clinicians, chemists, and physiologists.* It 
is mostly found towards the end of the first week, and resembles 
very much the milk of the mature woman in the mammae both of 
the male and female infant. The superficial milk-ducts are obstructed 
with epithelium ; the interior ones are dilated in many places and 
filled with a cuboid epithelium and a liquid which resembles colos- 
trum. This secretion may be absent, but it is frequently found in 
premature or still-births, though the mammae be but rudimentary. 
The dilatations will increase in size for weeks, and begin a retrograde 
development as late as the middle of the first year of life. 

The tendency to epithelial elimination, which is a peculiar feature 
in the newly-born, and which is so commonly observed on its skin, 
mucous membranes, and in sebaceous follicles and kidneys, appears 
to be very marked in the mamma of the newly-born. This discovery 
of Epstein renders the subject of our discussion very much clearer 
from an etiological point of view. 

The swelling and secretion of the gland may last a week or two 
when undisturbed. After it has been squeezed out ever so gently, 
a new secretion will follow and continue five or six weeks. Thus 
pressure of any kind should be avoided. It is barely possible that 
it is not always injurious, and that a gentle inunction of warm oil, 
which is so commonly used, may do no harm. But, as a rule, every 
sort of pressure occasions an attack of inflammation and, maybe, sup- 
puration. Though an abscess be ever so small, it is sufficient to destroy 
forever all or a part of the mamma, — a serious misfortune in a female. 
A swelled mamma must be left alone. Applications of cool or warm 
water, the cloth being well pressed out and covered with oil-silk and 
cotton or flannel, or of a mild lead wash, will answer well. Also 
applications of potassium iodide dissolved in glycerin, one part of 
the former in two or five of the latter, which are repeated every 
few hours. Extract of belladonna may be added to advantage. When 
suppuration cannot be avoided, the incision must not be delayed. 
It ought to be made at the greatest possible distance from the nipple, 
directed towards the nipple, so as not to cut the main milk-ducts, 
and treated antiseptically. Indurations remaining behind require 
frequent and gentle inunctions of an iodoform ointment (iodoform, 
1.0; ol. bergamot., 2 drops; adep., 6.0 to 8.0), or iodoform collodium. 
to be applied with a brush twice every day (iodof., 1 ; collod., 10 
to 20) in such a manner that only those scales of the application 

*Jacobi, in Gerhardt's Handb. d. Kinderkrankh., 1st vol., 2d part, p. 39 
of the 2d ed., 1882. 



96 TREATMENT OF THE NEWLY-BORN 

which are peeling off from the skin are removed before a new layer 
is applied over the dried-up previous application. No collodion 
should be employed so long as there is the slightest secretion from 
the surface or from a wound. In place of the iodoform, potassium 
iodide may be used. A very mild galvanic current of from two to 
six small elements, conducted through the induration by means of 
soft sponge electrodes moistened with salt water, has rendered me 
good service in many cases. 

Perimastitis, the inflammation of the surrounding connective tissue, 
may occur primarily, but is mostly the final result of traumatic mas- 
titis. It is liable to grow dangerous, unless incisions be made early 
and treated antiseptically with great care. I have met with not a 
few cases in which the suppuration of the connective tissue was very 
extensive, spread over a large surface, undermined the skin of the 
chest, axilla, and back, resulted in gangrene, erysipelas, or sepsis, and 
terminated fatally. Antiseptic solutions (applications, injections, irri- 
gations) must be used frequently, but ought to be mild. Carbolic 
acid should be avoided, for infants are easily poisoned by it. 

The mamma ought to be examined for angiomata in every baby, 
whether there be mastitis or not. Nsevi are by no means rare in 
this neighborhood, and ought to be destroyed at once, either by the 
application of fuming nitric acid when superficial or by the actual 
cautery (red-hot iron, galvano-cautery, or thermo-cautery) when 
they are deep-seated or form genuine vascular tumors, for they are 
liable to grow rapidly and prove dangerous to the female. 

9. Treatment of the Cord. 

The indications for the application of the ligature, and thereby 
the complete interruption of foetal circulation, appear to vary in the 
practice and teachings of obstetricians. When the baby has cried 
a few times, the majority apply the ligature and cut the cord. Others 
insist upon waiting for the collapse of the cord produced by that 
of the vein, while the arteries are still pulsating, and some will wait 
for the disappearance of the arterial pulse. A few facts should be 
remembered for the purpose of guiding the practitioner in individual 
cases, for the amount of blood entering, or retained in, the body of 
the infant is by no means an indifferent matter. 

If the ligature be applied after the cessation of the umbilical pul- 
sation, there are still six ounces of blood (one hundred and ninety- 
two grammes, according to Zweifel) in the placenta. If the latter 
be compressed by Crede's procedure, that amount is reduced to three 
ounces (ninety-two grammes). Thus the difference between the 



TREATMENT OF THE CORD 97 

two procedures means a difference of three ounces of blood in the 
circulation of the newly-born. That is an enormous addition to the 
usual quantity of blood, which in the infant slightly older is but 
little more than five per cent, of the total weight of its body. After 
all, it appears that a delay of the separation of the baby, when poorly 
developed and pale, and the admission of more blood to its circulation, 
are deserving of recommendation ; while, on the other hand, there 
may be an occasional indication for bleeding the infant.* 

The admission of a large quantity of blood, however, is no un- 
mitigated blessing. The blood-vessels of the newly-born are so thin 
and fragile that spontaneous hemorrhages on serous membranes and 
into the nerve-centres, etc., are by no means uncommon under normal 
circumstances. It is true that the destruction of superfluous blood- 
corpuscles is very rapid, — as rapid, indeed, as it is known to be after 
transfusion in the adult, — but some time is required to accomplish that 
end, and during that time hemorrhages may take place, and have been 
reported by Neumann and Illing and observed by me. This danger 
is sufficiently great to counterbalance the alleged observation of Hof- 
meier, according to whom babies, after deferred separation from the 
mother, lost less weight and commenced to increase sooner than those 
removed more speedily. However, Violet states that the former lost 
twenty ounces (six hundred and nineteen grammes), the latter but 
nineteen (five hundred and eighty-five grammes) — not much of a 
difference, though. 

Nor does Porak's observation, according to which congested babies 
exhibit a more intense degree of jaundice, lack confirmation. 

If the ligature be thin, it is liable to cut through the walls of the 
blood-vessels prematurely ; if too thick, it may not suffice to compress 
them satisfactorily. It ought to be applied at a distance of from 
one and a half to two and a half inches from the abdominal wall 
(three to five centimetres) ; not nearer, in order to avoid the effect 
of the great muscular power of the umbilical arteries inside the ab- 
dominal cavity. A second ligature is placed about an inch from 
the first, and the cord cut between them. It is a good rule, which 
must surely be adhered to in every case of thick cord, to apply an addi- 
tional ligature between the first and the abdominal wall, to avoid 
hemorrhage which may take place after the cord has commenced to 
shrink, from the insufficiently compressed arteries. The abdominal 
end of the cord is then wrapped up in a dry and soft piece of linen, 
lint, or borated cotton, placed on the left side of the abdomen, and 

* Archives of Pediatrics. March, 1888. p. 130. 
7 



9 8 TREATMENT OF THE NEWLY-BORN 

fastened, by means of a soft flannel bandage, which is wide enough 
to cover the larger part of the chest and all of the abdomen, so as 
not to slip. 

In wrapping up the end of the cord no oil or fat should be used. 
Warmth and dryness favor mummification ; moisture and exclusion 
of air, gangrene. This holds good also for the cord when it is sepa- 
rated from the living baby by an additional ligature, and in the dead. 
Thus, the former forensic axiom, which prevailed for decades after 
Meckel had demonstrated its fallacy as early as 1853, that a dry cord 
proved that the baby had lived, is absolutely worthless. Fatty sub- 
stances and moisture of any kind must be avoided. That is why it 
is best to omit the daily bath. Powdered bismuth subgallate, or zinc 
oxide, or iodoform, or salicylic acid (one part with forty or twenty 
parts of starch) may be dusted round the insertion of the cord and 
over the stump daily. The latter application is not necessarily useless 
(from the point of view of antisepsis), for the separation of the cord 
is a gradual one, and not uniform through the whole thickness of 
the amnion and the three blood-vessels. 

The size of the sore stump and the rapidity or slowness of cicatri- 
zation depend upon the thickness of the cord, the intensity of the 
line of demarcation, and the reactive inflammation. The latter are 
most marked in vigorous infants. As a rule, the surface is dry a 
few days after the falling of the cord, and cicatrization complete within 
twelve or fifteen days after birth. This normal process is, however, 
disturbed by careless handling, local irritation, and infectious influ- 
ences. In these unfavorable cases there is a serous or purulent secre- 
tion, and cicatrization may be deferred for many weeks. Under these 
circumstances local treatment is required. Carbolic acid ought to 
be avoided, for the newly-born and infant are easily influenced by 
its poisonous properties. Solutions of lead, zinc, or alum answer 
quite as well as any solutions do. As I said, however, it is best to 
avoid water. I recommend the powders of zinc oxide, bismuth sub- 
gallate, alum with starch, salicylic acid with starch, or iodoform. 
Such measures will always prove helpful ; to omit them in times 
of prevailing erysipelas or diphtheria is unpardonable. Perchloride of 
iron or subsulphate of iron must not be used. Under the hard coagu- 
lation formed by their application over the whole wound secretions 
will accumulate, cannot escape, are absorbed, and produce sepsis. 
I have seen babies die from applications of iron to the umbilical 
stump, as I know of women dying for the same reason when the 
hemorrhages from their uteri or from the lacerated vaginae were mal- 
treated in the same manner. 



UMBILICAL INFLAMMATION AND GANGRENE 



99 



10. Omphalitis. 

Inflammatory infiltration of the abdominal integuments which 
surround the stump, with swelling, pain, purplish discoloration, gan- 
grene, or abscesses, and consecutive peritonitis, occurs within a few 
weeks after birth, and is the result of traumatic or septic influences. 
The dermatitis requires applications of lead wash; tendency to sup- 
puration, moist antiseptic (or aromatic) applications, such as 
Thiersch's solution (salicylic acid one part, boric acid six parts, water 
one hundred and twenty-eight parts) ; the presence of pus, a large 
incision, with antiseptic after-treatment. Cold applications are not 
tolerated. Bathing is painful. Any of the antiseptics mentioned 
previously will render good service. Carbolic acid must be avoided; 
lysol, in a two-per-cent. watery solution, potassium permanganate I 
to 500 or 1000, thymol 1 to 1000, aluminum acetate two to three per 
cent., and when ulceration is extensive, powdered bismuth subgallate 
(better than in a vaseline ointment) will do much better. Ery- 
sipelas is no uncommon complication in certain epidemics ; absolute 
alcohol, ichthyol in water or with vaseline (ten to fifty per cent.) ; 
during the time of great irritation the lead and opium wash with 
attention to the effect of opium, which, however, is not readily absorbed 
through the swelled and inflamed tissue, are indicated. Generous 
feeding by a wet-nurse, alcoholic stimulants (from one to two tea- 
spoonfuls of whiskey or brandy daily), plenty of water, and evacua- 
tion of the bowels by injections are the additional aids in treatment. 
The main reliance is on the local treatment, — viz., large incisions and 
antisepsis. 

11. Umbilical Gangrene. 

This is the result of an inflammatory process, mostly in a pre- 
maturely born baby, or one that fell sick with diarrhcea. It may 
extend inward to the intestine and terminate in perforation. The 
prognosis is very bad except in the few cases in which there is a 
well-marked line of demarcation. The treatment consists in anti- 
sepsis and stimulation. 

12. Arteritis and Phlebitis. 

The former is very much more frequent than the latter. Arteritis 
is often connected with general sepsis, pneumonia, pleurisy, peri- 
tonitis, arthritis, and subcutaneous abscesses. The infection reaches 
the arteries from outside through the lymph circulation, begins in 
the connective tissue surrounding the vessels, and attacks the adven- 

LoFC. 



IOO TREATMENT OF THE NEWLY-BORN 

titia first. To discover the source of infection is sometimes very 
difficult; in his experiments Budin succeeded even in forcing septic 
material through the cord from beyond the umbilical ligature. Pus 
can seldom be squeezed out of the arteries, and the diagnosis is 
sometimes made at the autopsy only. The disease begins often before 
the complete separation of the cord, absorption taking place through 
the cord, which dries and shrinks irregularly, and admits infection 
through the newly formed cuts or fissures. 

The treatment is indicated by the causes, which are self-infection 
from a putrefying surface, infection by soiled fingers, cloths, baths, 
applications of any kind, the contact with a septic mother, or the 
contact with anything septic, — for instance, the pus of ophthalmo- 
blennorrhea, or the decomposing lochial discharges of a healthy 
woman. Thus the successful treatment is mostly preventive. The 
scissors, cloths, and sponges used for the newly-born must be aseptic. 
The baby must not be in the mother's bed, and must be attended 
before the mother on the days following her confinement. The 
hands touching the baby's body must be carefully cleaned and dis- 
infected many times a day, the cord and umbilical wound treated as 
detailed above. They should be kept tied up conscientiously. There 
should be no possible contact between them and the fecal discharges, 
be these ever so normal ; if there be diarrhoea the greatest caution 
is required, for the danger of infection is imminent. If the mother 
suffer from puerperal sepsis the baby may be permitted to nurse, 
but should, in the intervals, be kept in another room and carried into 
the presence of the mother for the purpose of nursing only, and 
contact avoided. The internal treatment is identical with that advised 
in omphalitis and gangrene. 

The symptoms of phlebitis differ sometimes from those of arteritis 
in this, — that there is more peritonitis of the hepatic region from the 
beginning, more epigastric meteorismus, more icterus. Now and then 
pus may be obtained by gently squeezing along the course of the vein. 
The infection is either direct, through the vein, in which an ulcerous 
process is sometimes found half an inch or an inch above the navel, 
or also through the lymph-current in the surrounding connective 
tissue and the adventitia of the vessel. The treatment cannot differ 
from that of arteritis. Recovery is possible when the absorption of 
the poison has not been very copious, or elimination progresses with 
absorption at an equal rate. A female baby of less than three pounds, 
in my experience, exhibited no other source of septic infection than 
a slight erosion or ulceration of the umbilical stump, with hardly any 
secretion. She recovered, though the process extended to the end 



SEPSIS. ACUTE FATTY DEGENERATION ioi 

of the second week, with temperature reaching sometimes 103 ° F. 
Chronic septico-pysemia, which lasts a year and more and furnishes 
the usual kind of abscesses all over, may sometimes be traced di- 
rectly to umbilical infection of a mild degree. Such cases may get 
well when the abscesses one and all are incised and treated anti- 
septically. To what extent an antistreptococcus serum may be found 
available (certainly in such cases only in which the streptococcus is 
the infecting agent) remains to be seen. Crede's ointment should 
be tried. 



13. Puerperal Sepsis. Acute Fatty Degeneration {Buhl). Epidemic 
Hemoglobinuria {Winckel). 

The treatment outlined in the last chapters is to a great extent 
also that of the puerperal sepsis of the newly-born contracted before 
birth, or immediately after, from the mother (umbilical changes, fever 
or collapse, peritonitis, pleuritis, pneumonia, meningitis, jaundice, 
diarrhoea, — in fact, all the possible symptoms of septico-pyaemia). 
It takes more than " an ounce of prevention ;" but, after all, pre- 
vention is all that can be done. Recovery is a bare possibility only, 
but should be hoped for; that is why internal disinfectant treatment 
(Crede) and attention to abscesses should not be omitted. 

Acute fatty degeneration of the liver, heart, and kidneys, also of 
the lungs and the intestinal villi, with multiple hemorrhages, jaundice, 
cyanosis, vomiting, and diarrhoea, does not seem to get well. It lasts 
from one to two weeks. It need not necessarily be the result of some 
acute influence. Fatty degeneration (chronic) may be a slow process 
of intra-uterine malnutrition. George T. Elliot, forty years ago, 
presented to the New York Pathological Society a full-grown foetus 
all of whose tissues were in fatty degeneration to such an extent that 
during the extraction of the foetus necessitated by the existing breech 
presentation limbs and parts of limbs were torn off. Almost the 
same may be said of epidemic hsemoglobinuria (Winckel), which 
exhibits the same symptoms, to which is added the presence of haemo- 
globin in the urine. It is of a brownish-red color and contains no 
blood, but renal and vesical epithelia, casts, and cocci. 

Sepsis derived from the mother need not be of long duration. 
Indeed, the embryo appears to be better protected against the poisons 
of the maternal blood than the foetus, for in the foetus its placental 
villi float free and loose in the maternal blood, while in the embryo 
(as also in mammals) the maternal and the foetal tissues meet like 
the interlaced fingers of two hands. 



102 TREATMENT OF THE NEWLY-BORN 

14. Umbilical Hemorrhage. 

This may take place from the arteries either before or after the 
separation of the cord. Its treatment is either mostly preventive 
or the indications become so clear in every individual case that it 
becomes easy to fulfil them. Though the pulmonary aspiration and 
the great contractility of the muscular layers of the arteries render 
a hemorrhage difficult, even when no ligatures were applied, an 
insufficient development of those muscular fibres, or the presence of 
asphyxia, or atelectasis, or a pneumonia, may produce a disposition to 
bleed. That is why the ligature or ligatures should be tied accu- 
rately. In such cases of bleeding it may become necessary to apply 
an additional ligature. The arterial power being greatest in the 
abdominal cavity and near the umbilical ring, the cord must not be 
cut near the body. Two ligatures, as described above, are a fair pre- 
ventive. Tight abdominal bandages impede circulation, and should 
be avoided. When the cord is cut too short or torn off, it may be 
impossible to secure the vessels ; in such cases two long harelip 
needles should be run through the abdominal wall near the vessels, 
crosswise, and a strong ligature tied underneath them. The same 
procedure may be resorted to when the hemorrhage takes place after 
the separation of the cord, either from the blood-vessels or from 
the slowly healing surface, in consequence mostly of inconsiderate 
handling. When the hemorrhage ceases, a moderate compression of 
the wound, which is covered with iodoform or the salicylic acid and 
starch powder and borated cotton, by means of a bandage, will answer 
well. In obstinate cases antipyrin in a twenty- or fifty-per-cent. solu- 
tion should be applied. No iron. When the surface is granulating 
the proliferations may be touched with the solid stick of silver nitrate. 

All such cases yield a better prognosis than those resulting from 
haemophilia, congenital syphilis, general sepsis, or acute fatty degen- 
eration. In these conditions the blood coagulates with even greater 
difficulty than that of the healthy newly-born, and not infrequently 
all attempts at stopping the bleeding are liable to prove futile. Be- 
sides, internal hemorrhages are very frequent (stomach, intestines, 
lungs, kidneys). The ligation of the whole mass is often unsuccessful 
because the stitch-channels will also bleed ; chemical styptics are too 
often useless; plaster of Paris has sometimes proved successful, and 
the actual cautery has proved advantageous in a few cases. But 
the majority of such cases terminate fatally. Antipyrin solution 
(twenty-five or fifty per cent.) should be applied, followed imme- 
diately by a few drops of a saturated solution of tannin. Feeding 



UMBILICAL HEMORRHAGE. ICTERUS 103 

and stimulants (whiskey, musk, ether, camphor) are self-understood. 
Gelatin may be used here as in other hemorrhages, both externally 
and subcutaneously (a two-per-cent. sterile solution). 

If the case be one of syphilis, daily subcutaneous injections of 
corrosive sublimate should be tried (1 to 1000). A suggestion of 
Bienwald, who applied fresh coagulable blood of a healthy person 
to the bleeding wound of a hemophilic patient, with the result of 
causing coagulation and insuring recovery, is here reported for what 
it may be worth. A. E. Wright claims a styptic effect of a solution 
of fibrin ferment and calcium chloride. 

15. Icterus. 
A certain degree of yellowish discoloration of the skin is the 
result of the normal changes of hsematin deposited in the skin during 
the rapid transition from foetal to postnatal circulation. When by 
retarded separation of the newly-born from the mother, and com- 
pression of the placenta, the amount of blood in the circulation of 
the infant is unduly increased, this form of haematogene jaundice 
is rather more developed. Besides, the disintegration of many blood- 
cells causes directly an increase of bilirubin. The simplest form of 
hepatogene icterus is produced by the sudden diminution of the blood 
circulating in the vessels of the liver, which encourages the exos- 
motic transition of bile from the bile-ducts into the adjoining blood- 
vessels. That is why babies who rapidly lose weight (and blood) 
are very liable to exhibit intense degrees of jaundice. Another cause 
of jaundice of the newly-born is the immediate absorption of bili- 
rubin into the circulation ; for meconium having accumulated bili- 
rubin since the third month of utero-gestation, and peristalsis being, 
as a rule, slow, absorption becomes easy through the open ductus 
venosus Arantii, which remains patent at least a week in the large 
majority (Quincke, seventy-seven per cent.) of cases, and through the 
hemorrhoidal plexus (v. hemorrh. media). If peristalsis be very 
slow, jaundice may begin in the second week. That is why premature 
babies in whom the ductus venosus is large are apt to be much 
jaundiced; and why Elsaesser found no jaundice in three cases 
that exhibited a closed ductus ; and why, finally, many a liver of 
newly-born icteric babies does not participate in the icteric process.* 
All of these forms of jaundice, while mild, require no treatment. Duo- 
denal catarrh will produce, in rather rare cases, icterus in the newly- 

* Cases like those of Hayem, in which the blood contained bile while the 
nrine had none, are rare indeed. 



io4 



TREATMENT OF THE NEWLY-BORN 



born, as it does in advanced age. That is why the feeding and the 
digestion of the baby must be carefully watched and the air pure. 
The routine administration of syrup of rhubarb is a mistake on the 
part of the female busybodies which should be discouraged. Maybe, 
also, some of them can be taught that acid cow's milk and indis- 
criminate feeding in general, and exposure, tight bandaging, and cold 
feet, can do still more harm than even their medicines. Icterus 
resulting from congenital obliteration of the large biliary ducts, or 
from congenital cirrhosis, or from acute fatty degeneration, or from 
epidemic hemoglobinuria is incurable. Icterus during septic infection 
is a bad symptom, and rarely terminates otherwise than in death. 
Icterus depending on congenital syphilis of the liver is grave, but I 
have met with several cases that recovered. A thorough and energetic 
antisyphilitic treatment is the only safeguard in such cases. It may 
prove unsuccessful, however, because the syphilitic . process of the 
connective tissue is not confined to the liver, but extends to the rest 
of the organs. Mercury must be administered for a long time, a 
twentieth or a twelfth of a grain of calomel three times a day ; care- 
ful inunction of a scruple of blue ointment daily; or one-thirtieth 
of a grain of corrosive sublimate in a one-fifth of a per cent, solution 
of distilled water for subcutaneous injection daily. In the beginning 
of the treatment two of these medicaments may be combined, or one 
of them, together with the internal administration of from three to 
five grains of potassium iodide daily, in three doses, which are given 
after meals. The internal administration of mercuric bichloride is 
also well tolerated; one-one-hundredth of a grain may be given in 
a teaspoonful of water every two or four hours, and continued many 
weeks. 

1 6.. Melcena Neonatorum. 
Hemorrhage from the bowels (more frequent than from the 
stomach) occurs on the second or third day of life, very rarely before, 
but sometimes later within the first week. Syphilis, acute fatty de- 
generation, epidemic hemoglobinuria, and sepsis of other varieties — 
also asphyxia and atelectasis, together with the normal incompetency 
of foetal tissue — cause a predisposition; also pulmonary obstructions, 
cardiac disease, and a widely open ductus Botalli with consecutive 
intense congestion. Leopold Fischer (Munch, med. Woch., 1897, 
No. 19) suggests as one of the causes the delayed cutting of the 
cord. A baby of three thousand grammes contains about one hun- 
dred and sixty of blood. When eighty or one hundred grammes more 
are pressed into its circulation from the placenta, the blood-pressure 



MEL^NA 105 

may become too high. But is all of this amount really entering 
when no pressure is exerted ? A thrombus emanating from the latter, 
or one coming from the ductus venosus Arantii (Landau), may cause 
an embolic ulceration of the stomach or duodenum. The blood is 
fluid or coagulated, rather black, like that of hsematemesis in advanced 
age. It is, however, mixed with the food and rather reddish when it 
was swallowed while nursing. A mistake in diagnosis may happen 
when blood is swallowed during an operation on the lip or cheek or 
during an epistaxis resulting from an injury. A single observation of 
the latter kind was published lately, and generalized as the cause of 
melaena. Bleedings of this kind do not exhibit the pallor, cyanosis, 
and collapse of the genuine affection, provided such an epistaxis is 
really traumatic. In most cases, however, a congenital epistaxis is 
itself the result of septic infection (or syphilis). 

The quantity of blood evacuated from the bowels is sometimes 
enormous, particularly in view of the fact that the weight of the blood 
in the body of the newly-born amounts to little more than five per 
cent, of the weight of the baby. The cases complicated with vomiting 
are the worst. These result mostly from the presence of ulcerations 
in the stomach and duodenum. Hemorrhage into the peritoneal 
cavity is exceptional only. Competent respiration and an aseptic um- 
bilical wound are the best preventives. Babies should cry from time 
to time to stimulate and strengthen both circulation and respiration. 
The treatment consists in applications of ice to the epigastrium, while 
the limbs are kept thoroughly warm by artificial means. Tincture 
of chloride of iron may be given in drop doses. Food is to be given 
at a low temperature. Rectal alimentation is mostly useless because 
of the frequency of discharges. In a desperate case of anaemia and 
collapse the subcutaneous injection of a sterilized salt-water solution 
may prove helpful. I could not convince myself of the usefulness of 
subcutaneous injections of ergot; but gelatin in sterilized solutions 
(two per cent.) may be used subcutaneously. In a case lately reported 
a solution of from three to five per cent, was given internally, two 
tablespoonfuls every two hours, and two hundred and fifty cubic 
centimetres (eight ounces) of a three-per-cent. solution were injected 
twice daily into the rectum. As the baby carried these large quan- 
tities, the case looks like a favorable one, prognostically.* Altogether, 
about three cases of melaena out of five have recovered. 



* Ernst Levy and Hugo Brims (Mittheil. Grenzgeb., vol. x., 1902) report 
that gelatin, which was used by the Chinese in the third century A.D., may 
cause thromboses not only on the bleeding surface but in undesirable places 



106 TREATMENT OF THE NEWLY-BORN 

17. Trismus and Tetanus. 
Its prognosis is not quite so bad as it was believed to be for- 
merly. Now and then recoveries have been reported, and I have 
seen them myself, though the cases observed by me have not been 
very numerous. The prognosis is better when trismus appears at a 
later period after the separation of the cord than usual, and when 
its course is protracted. Cases lasting more than five or six days are 
rather promising. Such as set in early and exhibit a high tempera- 
ture (from 106 to in° F.)., with disturbances of respiration and 
great inanition, are bad. As a preventive, it has been proposed to 
remove women, for the time of their confinement and recovery, from 
districts where trismus is endemic. At all events, the greatest care 
should be taken of the umbilical wound, through which most of the 
invasion of the specific bacillus takes place. Towels and clothing- 
must not have lain on the floor, dust must be carefully excluded. 
Some of the cases are mild, — that is, not fatal. Maybe they are 
those only which are due to excess of temperature, high or low, 
— there are those of " rheumatic" origin, — or to lesions of the brain 
or medulla oblongata. Food must be introduced through the rectum 
or the nose, and as much water as possible. For days after no food 
could be swallowed when introduced into the mouth, the patients 
were sometimes able to swallow whatever was thrown into their 
pharynx. By means of a medicine-dropper or a small teaspoon fluids 
may be poured down. Medicines must be administered subcutane- 
ously, atropine sulphate in doses of one-one-thousandth or one-six- 
hundredth of a grain a number of times daily ; curare, one-twelfth 
to one-third ; it paralyzes the muscles and works well when given in 
such doses as will counteract the reflex irritation of the muscles 
without paralyzing them (Scharlau in Festschrift) ; extract of cala- 
bar, one-half of a grain. A few of my cases got well with chloral, 
mostly per rectum, in doses of from one to five grains from six to 
ten times (!) a day, and occasional inhalations of chloroform. High 



also, and, unfortunately, tetanus, the bacilli of which are quite frequently found 
in the gelatin of the market. The tetanus bacilli require at least forty minutes' 
heating at ioo° C. ; that degree of heat cannot be obtained by mere boiling, 
the less so because colloid solutions of two or ten per cent, gelatin require more 
heat than water. Perfect safety cannot be attained except in moving steam. 

Paul Krause (Berl. kl. Woch., July 21, 1902) advises the sterilization of 
the gelatin solution on five successive days, one-half hour each time, in vapor 
of ioo° C, and also that there should be a place (a hospital) at which practi- 
tioners could at any time procure such a sterilized solution. 



TETANUS. BLENNORRHEA 107 

temperatures may be influenced by antipyrin or phenacetin, com- 
bined with whiskey or brandy. Bathing is contraindicated because 
the baby bears no handling. Even applications of cold water for 
the purpose of reducing high temperatures, if used at all, should be 
local only, and made without turning or tossing the patient. 

All this medication is not rendered superfluous by the subcutane- 
ous administration of the antitoxin, first introduced by Tizzoni and 
Cattani. One case out of four of Escherich recovered under the 
use of three doses of three decigrammes (five grains) each injected 
in the course of two days. The chemical poison (" tetanin") evolved 
out of the invading bacilli is not absorbed at once ; the invasion is 
more or less persistent and should be stopped in the admitting wound 
(mostly the umbilicus) by the actual cautery, or by applications of 
tincture of iodine, or of a one- or two-per-cent. solution of iodine 
trichloride, or a one-half-per-cent. solution of potassium hydrate, or 
a one-twentieth-per-cent. dilution of hydrochloric acid, or a one-per- 
cent, dilution of cresol (Sahli, Deutsche med. Zeit., No. 11, 1896). 
Similar rules are given by the Health Department of New York. 
Of the antitoxin, twenty cubic centimetres are a dose for an adult; 
accordingly, one cubic centimetre seems to be appropriate for the 
newly-born (Archives of Pediatrics, July 1, 1897). Perhaps the best 
method of introducing the antitoxin in doses of from one to three 
cubic centimetres is the lumbar puncture in as large a quantity as 
that of the cerebro-spinal liquor which was first withdrawn. To 
facilitate the operation, the opisthotonos should first be relieved by 
chloroform or chloral or morphine. 

18. Blennorrhcea. 
Blennorrhceic conjunctivitis may be prevented by repeated dis- 
infectant injections into the vagina of the woman in labor. For that 
purpose a solution of three parts of carbolic acid in one hundred of 
water, or one of mercuric bichloride in one or two thousand of water, 
is sufficient. After the newly-born has been bathed, a few drops of 
a two-per-cent. solution of silver nitrate (or a one-twentieth-per- 
cent, solution of mercuric bichloride) are applied to the cornea. 
When the disease is established, both eyes are affected in most cases. 
When but one, the healthy eye should be covered with a disinfect- 
ing lotion and borated cotton, and its infection by sponges, towels, 
water, and fingers guarded against with the greatest care. The 
diseased eye must be kept scrupulously clean by pouring tepid 
water over the cornea, or (and) removing the pus by means of small 
pellets of borated cotton. To succeed in this the upper and lower 



108 TREATMENT OF THE NEWLY-BORN 

eyelids must be turned out. This is not always easy, and is never 
satisfactory unless the cornea becomes perfectly visible during the 
manipulation. Once a day the application of a mitigated stick of 
silver nitrate (nit. arg., I ; nit. sod., 2) is useful. It may be substi- 
tuted by a two-per-cent. solution of silver nitrate in water. In both 
cases the diseased surface should be washed with a mild solution of 
table salt afterwards, and ice-cloths, small and as well pressed out as 
possible, applied every ten minutes or oftener. When the cornea is 
ulcerated, a few drops of a solution of atropine sulphate (1 to 200) 
may be instilled several times daily. 

Lately G. Schallern experimented on the eyes of nine hundred 
and seventeen new-born in the obstetrical clinic of Gottingen. Not 
more than two babies became affected, and on the eighth day only; 
all were saved. The slight irritation following (in some cases) the 
application of the two-per-cent. solution of silver nitrate subsided 
without any injury. When that irritation is observed, no new appli- 
cation should be made in the next twenty-four or thirty-six hours 
(Archiv f. Gyn'dk., 1897, p. 86). Of nineteen hundred and seventeen 
cases reported by Runge, not one was affected after the treatment 
with silver nitrate solution ; of that number, nine hundred and twenty- 
eight had a one-per-cent. solution only to avoid the local irritation 
sometimes encountered with a stronger solution. The application 
should be made within an hour after birth. 

19. Umbilical Fungus {Granuloma). Adenoma. Cysts. 

The umbilical stump requires frequent inspection. Unless it cica- 
trizes speedily, granulations will spring up from its surface and form 
into small tumors. They are either sessile or pedunculated, and are 
apt to grow very fast. They are not sensitive, but apt to bleed. 
In some cases they are discovered on very close examination only, 
and may remain many years, even to advanced age. Exceptionally 
such a fungus is not, or but partly, the result of granulation, but 
consists mainly of the remnants of the omphalo-mesenteric duct (with 
unstriped muscular fibres, tubulated glands, and cylindrical cells) or 
of the allantois. Once it was found by Virchow to be a sarcoma. 
Waldeyer met with some that were adeno-sarcomata. 

Usually it requires no excision, but only cauterization or astrin- 
gent and antiseptic applications. Silver nitrate may be used, but 
must immediately be neutralized by sodium chloride. Other appli- 
cations are: a drop of liquor subsulphatis ferri once or twice daily; 
bismuth subgallate; iodoform; one part of salicylic acid with five 
parts of starch. If the granuloma is large, or when it returns, it 



UMBILICAL FUNGUS AND HERNIA 109 

should be removed with the scissors and the stump scraped off. 
Dry antiseptic treatment is to follow (bismuth subgallate, aristol, 
nosophen). The persistent omphalo-mesenteric duct, which presents 
itself as a small tumor after the cord has fallen off, should not be 
taken for a granuloma. This anomaly is observed in different de- 
grees. In the milder forms, even those in which a fine sound entered 
the intestinal tract, the actual (thermo- or electro-) cautery would 
destroy the tumor and cause the fistula to close, Korte's assertion to 
the contrary {Deutsche med. Woch., 1898, No. 7) notwithstanding; 
but when the fistula is so large as to admit a prolapse of the intes- 
tine into it, nothing short of a careful aseptic operation will answer. 
The incision must surround the tumor, and be carried far enough to 
permit the diverticulum to be drawn out. It has then to be sepa- 
rated from the jejunum, the intestinal wound is closed with sutures, 
and the bowel returned to the peritoneal cavity. Several such opera- 
tions have proved successful. 

Umbilical cysts may owe their origin to remnants of the omphalo- 
mesenteric duct or of the urachus. A few were due to atheroma, 
or were echinococci, or dermoids, or due to a strangulated umbilical 
sac. Possibly a strangulated peritonitic exudation dating from 
early fcetal life may also be credited with the same result, exactly like 
some of the hydroceles of the spermatic cord. 

20. Umbilical Hernia {Omphalocele). 
Congenital umbilical hernia (exomphalos) is called a fissure of 
the median line of the abdominal wall ; it is the result of an arrest 
of development. When the fissure is small and the sac contains 
intestine only, the condition is considered incurable. There is no 
reason why an operation on these cases, in which the abdominal defect 
is small, should not be at least as successful as those on more pro- 
nounced ones ; for when the sac is large, containing at least a portion 
of the liver, together with intestine, the contents may be reduced 
and the cases cured. Twenty-four such cases have been collected 
by Kocher.* C. Brenz reported the case of a girl weighing two 
thousand seven hundred grammes at birth. When the hernial con- 
tents had been reduced, which was accomplished with difficulty, he 
caught the edges of the sac by means of a pair of pincers, removed 
it with scissors, applied three percutaneous ligatures, removed the 
clamp, applied the actual cautery to the stump, and covered it with 

* A. Jacobi, The Intestinal Diseases of Infancy and Childhood, Detroit, 
1887, p. 267. 



HO TREATMENT OF THE NEWLY-BORN 

antiseptic dressings. Both these and the ligatures were removed on 
the eighth day. The operation proved successful, though there was 
peritonitis as early as twenty-four hours after birth. D'Arcy Power 
reports an unsuccessful one (" Surg. Dis. Child.," 1895). Hallet 
{Rev. de Gynec. et de Chir. Abdom., 1900) collected fifty-eight opera- 
tions performed within thirty-six hours after birth, of which fifteen 
cases died ; seven performed between the thirty-sixth and forty- 
eighth hours, of which three died ; two on the third day, of which 
one died ; four after the third day, all of which died. The operation 
is contraindicated when omphalocele is complicated with other con- 
genital anomalies. 

Acquired umbilical hernia, which contains small intestine and 
peritoneum, and is produced by the large size of the cord, by leanness 
and insufficient development of the baby, by the muscular insufficiency 
and abdominal flabbiness of rhachitis, and by screaming, coughing, 
and the straining consequent upon diarrhoea, constipation, phimosis, 
or anal fissure, demands the treatment indicated by these causes, and 
reduction, which is almost always quite easy, and retention, which is 
by no means so easy, within the abdominal cavity. The ordinary 
trusses are unavailable, or even injurious. Whatever appliance is 
used should be larger than the aperture and not too hard. Linen or 
lint compresses, plates of cork covered with linen or lint, may be held 
in position by means of a bandage, to which they can be fastened by 
stitches or pins. Knitted bandages are more useful than those of 
linen, cotton, or flannel cloth. Adhesive plasters are used frequently, 
but are generally too irritating to the sensitive surface of the infant. 

Incarceration and strangulation of an umbilical hernia are very 
rare, but there is on record a fair number of cases in which herniotomy 
was performed successfully on infants of a slightly advanced age. 

Inguinal hernia is a curable disease. When the short and straight 
inguinal canal of the newly-born becomes more oblique and the adja- 
cent fat increases in the course of a few years, the rupture will dis- 
appear, provided a proper truss has been retained for a long time. 
During that period the intestines must not be allowed to protrude at 
all. The truss must be worn day and night, with the exception of 
such times when the infant is sleeping quietly. A good fit does not 
mean undue pressure. The testicle must be closely watched. It is 
found high up in the scrotum, behind the hernia. Sometimes it has 
not descended into the scrotum, and is then mostly discovered in 
the inguinal canal. By gently pressing it downward and applying 
the truss above, we not only protect it but facilitate a complete de- 
scensus. Mr. William Coates's (1848) appliance "consists simply 



CONGENITAL CONSTIPATION III 

of a skein of lamb's wool ; for infants Berlin wool is preferable. This 
encircles the pelvis, one end being passed through the other at a 
point corresponding with the inguinal ring; the free end is carried 
between the thighs, and is fastened behind to that portion which 
forms the cincture. This simple and cheap contrivance can be worn 
during the morning and evening ablutions, and then changed for a 
dry one. No attention is required on the part of the nurse, except 
at the moment of changing." (D'Arcy Power, "The Surgical Dis- 
eases of Children," Philadelphia, 1895, p. 414.) 

For such cases as prove too obstinate a radical operation becomes 
advisable; in some it is inevitable. (D'Arcy Power and the special 
works on surgery. See also Digestive Organs.) 

21. Congenital Constipation. 
Malformations of the intestinal tract, such as strictures or com- 
plete interruptions, will either terminate fatally (when inaccessible) 
or require surgical treatment. The latter class includes imperforate 
anus and rectum. In these cases, the obstruction being complete, 
we cannot speak of constipation. This latter condition may, however, 
be found to depend on an anatomical peculiarity which is quite fre- 
quent, and may give rise to mistakes in diagnosis and treatment. 
The colon descendens of the newly-born is quite long. The sigmoid 
flexure, which I have found to measure as many as thirty centimetres 
(twelve inches), is bent upon itself several times in the narrow pelvis. 
Thus the convolutions of the intestine will press upon and compress 
one another * to such an extent as to result in obstinate constipation. 
In some extreme cases the babies died without or with colotomy, 
which was performed on the strength of a mistaken diagnosis. The 
treatment of that congenital form of constipation must be adapted 
to the anatomical condition which gives rise to it. Rectal injections 
alone, non-irritating (tepid water or saline solutions), in large quan- 
tities, are rational. They must be made daily, at least once a day, 
and continued up to the completion of the fifth or sixth or even 
seventh year. At that period the normal relations of the several 
parts of the intestine are established, the pelvis becomes larger, and 
evacuations of the bowels easier. No purgative medicines must be 
resorted to, inasmuch as the obstacle is mechanical only. There is, 
however, a single indication for their administration, — viz., those 
symptoms depending upon constipation, which point to the absorp- 

* A. Jacobi, The Intestinal Diseases of Infancy and Childhood, Detroit, 
1887, p. 184. 



H2 TREATMENT OF THE NEWLY-BORN 

tion of intestinal toxins above the obstruction. Septic fever, high 
temperatures, and serious reflex symptoms — such as convulsions — 
may require the speedy evacuation of the bowels by means of mild 
purgatives. Powerful medicines are rarely demanded ; in most cases 
a teaspoonful of honey or of sweet butter will sufhce. Further advice 
will be found in the discussion of constipation. Though such occur- 
rences be rare, they should be looked for. (See " Non Nocere" in 
Trans. Eleventh Intemat. Med. Congress, or N. Y. Med. Record, May 
19, 1894.) Very bad cases may lead to early dilatation of the colon, 
an anomaly which may be congenital in rare instances. Small diver- 
ticula may occur in the sigmoid flexure (also in the appendix) with 
rapid dilatation as a result, followed sometimes by perforation, some- 
times by inflammation in the mucous membrane and submucous tis- 
sue, peritonitis, torsion of the intestine, and adhesions. Dilatation 
is also apt to favor muscular hypertrophy by overaction and by intes- 
tinal colitis resulting from irritation by faeces and by toxins. 



IV 

Diseases of the Blood and Constitution 

i. Anosmia. 

An^ml\ is often the result of an hereditary predisposition, or it 
is congenital from some accidental cause. Mothers who suffered 
much during their pregnancies or were delicate themselves are liable 
to give birth to anaemic and puny infants. Premature infants, or 
those afflicted with' congenital diseases, such as " cyanosis" or neo- 
plasms, or smallness of heart and arteries, are anaemic and apt to 
remain so. Another cause of idiopathic or primary anaemia is found 
in actual loss of substance by copious suppuration, excessive exuda- 
tions in pneumonia and pleurisy, or by actual hemorrhages, the results 
of which are in some cases perceptible through a whole lifetime. 
They are quite frequent in the newly-born or young, in true melaena, 
haemophilia, umbilical bleeding, and sometimes even in kephalhaema- 
toma; from harelip operations or ritual circumcision; from the pro- 
longed losses by rectal polypi; in older children from epistaxis occa- 
sioned by coryza, heart disease, or abdominal stagnation ; from ulcera- 
tions in diphtheria; from trauma. Acute anaemia thus caused re- 
quires external and internal styptics, the closure of wounds, the appli- 
cation of ice, and, mainly when parenchymatous bleeding is obstinate, 
the external use of a twenty- or even fifty-per-cent. solution of anti- 
pyrin. The subcutaneous injection of fluid extract of ergot, the 
internal use of lead acetate (hourly doses of two or five centigrammes 
(one-third or three-fourths grain), may be given ten or twelve times 
without fear), or of liquor ferri perchloridi (from five to ten drops 
amply diluted), or of calcium chloride from five to twenty grammes 
daily (0.3 to 1.25), stimulants internally, externally, and subcutane- 
ously, ligature around the extremities so as to compress the veins, 
warming of the surface, transfusion of defibrinated blood, or of a 
sterilized salt solution (6 to 1000) are apt to meet the most urgent 
necessities. 

So far as chronic ancemia is concerned (it is seldom " primary," 
but almost always secondary to some tangible or occult cause which 
ought to be sought out), I cannot do more than simply allude to 
its direct and indirect causes for the purpose of obtaining the indi- 
cations for treatment. Among the former are prominent an insuffi- 
cient amount or an improper composition of food and an insufficient 

8 113 



ii 4 



DISEASES OF THE BLOOD AND CONSTITUTION 



supply of oxygen. Poverty with its wants, its squalid and airless 
dwellings, and overwork in overcrowded school-rooms, are all power- 
ful sources of widespread anaemia; they become social problems 
more than merely medical questions. Among the indirect causes I 
count every disease of more than a temporary character ; all those ail- 
ments which so change the alimentary or digestive organs as to inter- 
fere with nutrition ; slow hemorrhages ; intestinal worms, which are 
sometimes borne without symptoms, sometimes irritate and annoy 
(oxyuris, ascaris), sometimes, however, interfere with assimilation 
to such an extent as to cause the gravest forms of anaemia (ascaris, 
taenia, bothriocephalus) ; diseases of the organs of respiration, cir- 
culation, and elimination (kidneys) ; all feverish diseases, and par- 
ticularly the infectious fevers (scarlatina, malaria, least of all typhoid 
fevers, unless they result in chronic intestinal ulcerations) ; diseases 
of the lymph system (including what is meant by " lymphatic con- 
dition" in the writings of many modern authors), most of which 
are accessible to successful treatment. It is true that pseudoleu- 
kemia, leucocythaemia, and pernicious and kindred anaemias offer the 
same difficulties which we meet in the adult ; but the many glandular 
swellings — " scrofulous" or not — permit of successful treatment, both 
preventive and curative. 

All of these affections, the number and names of which I do not 
care to multiply, are the more dangerous, and require the more dietetic 
and medicinal attention, the greater their detrimental influence during 
infancy and childhood, — that is, during the period of growth, in which 
the organism has not only to sustain itself, but to increase steadily. 
The latter consideration is a very important one. It includes the 
necessity to which I have alluded in a previous chapter, not to permit 
a morbid condition, either acute or chronic, to run its full course 
without interference. A disease shortened a day, a sleepless night 
less, a dozen diarrhoeal movements prevented, a racking cough 
soothed, a convulsion interrupted, an excessive temperature relieved, 
are just as many prophylactic points gained and as many causes of 
persistent anaemia mitigated in their dangerous influences. 

These considerations are the more weighty the younger the pa- 
tient ; for in regard to anaemia the young are in a very precarious 
condition indeed. The infant (and child) has less blood in proportion 
to its entire weight than the adult; this blood has less fibrin, less 
salts, less haemoglobin (except in the newly-born), less soluble albu- 
min, less specific gravity, particularly between the second and twelfth 
months of life, and usually more white blood-corpuscles. It has a 
specific gravity of but 1045 or I0 49 compared with that of 1055 m 



ANEMIA 115 

the adult. The total amount of blood in the young is relatively 
small. Its weight, compared with that of the body in the newly- 
born, is 1 to 19.5. The relative figures in the adult are 1 to 13.* 

Hence it follows, from a practical point of view, that it is impor- 
tant not to permit the proportionately small amount of blood in an 
infant or child to be unduly diminished or diluted. That is why the 
subject of feeding and digestion is of such paramount weight in 
pediatrics. 

While it is a good rule to be careful in regard to the amount of 
food to be given in the beginning of a feverish disease, a fair quan- 
tity should be allowed after a while, provided it is fluid and well 
selected. Unless there be a contraindication in the condition of the 

* According to the researches of Ernst Schiff ( Jahrb. d. Kinderheilk., vol. 
liv.), the specific gravity of the blood of the newly-born (male or female) is 
1080 to 1070 in the first six days, in the following four days 1070 to 1060, a little 
higher in the day than in the night, less in the icteric after the fourth day, 
more in the well developed than in the weak, and more after delayed ligature 
of the cord. 

The blood of the newly-born, the infant, and the child undergoes rapid 
changes. According to Monti (Wiener Med. Presse, 1894, No. 41), the specific 
gravity at birth is 1056 to 1066, at from two to four weeks 1056 to 1059, at 
from two to twelve months 1049 to 1052, at from two to ten years 1050 to 1056. 
Its specific gravity increases with larger body weight, with perspiration, in pneu- 
monia (rapid fall during crisis), and in the feverish state of malaria, typhoid, 
and pleurisy, frequently also during cardiac diseases. It diminishes rapidly 
after drinking, in acute nephritis (1047 to 1038), in non-cardiac chorea, in 
tuberculosis, dyspepsia, and intestinal catarrh. In all forms of anaemia it may 
vary from 1040 to 1028. According to Max Carstanjen (Jahrb. f. Kind., vol. 
Hi.), there are on the first day of life many polynuclear leucocytes, few lympho- 
cytes, between the sixth and ninth days both forms are equal, on the twelfth 
many lymphocytes with plenty of transition iorms. Until the third day there 
are many nucleated red blood-cells ; no increase of eosinophile cells at that time. 
The leucocytes are rather more numerous in the nursling than they are 
in the adult; Hayem says 18,000 to 5,368,000, Alfred Japhe 13,500, with pre- 
dominance of the mononuclears, and only forty-two per cent, of polynuclears. 
These are not increased in intestinal diseases, unless there be toxins of putre- 
faction or of pathogenic bacteria. There is an increase of leucocytes in most 
acute infectious diseases, except when the prognosis is a very bad one the 
first day of the illness, or in typhoid or malarial fevers, in pneumonia, and in 
the puerperal sepsis of the very young. 

The specific gravity corresponds mostly with the number of erythrocytes 
and the amount of haemoglobin. Both are high when the cutting of the cord 
was delayed. Haemoglobin and iron run mostly parallel. The percentage of 
iron is low in the nursling, in nephritis ; it grows when exclusive milk feeding 
is stopped and cereals, fruit, and animal foods are given. It increases very 
gradually; even about puberty it does not reach the percentage found in the 
adult. 



Il6 DISEASES OF THE BLOOD AND CONSTITUTION 

stomach, a fair amount of albuminous nutriment (milk) should be 
administered, with the addition of such foods as contain more iron 
(animal foods, cereals). During protracted diseases the danger of 
inanition becomes imminent, still more in the young than in the adult. 
Convalescence requires generous feeding and stimulation also, with 
this restriction, that the meals should be small and frequent and the 
stomach sustained all the time. In this way many a case of secondary 
anaemia may be avoided. (Chapter I.) 

Babies become anaemic when their mothers or nurses have too 
little milk, or when the supply is ample but of improper quality. 
Nursing during a subsequent pregnancy ought to be forbidden. It 
must not be continued too long, certainly not beyond the protrusion 
of the first group or groups of incisors. Nor must it be continued 
beyond the tenth month if at that time no tooth has made its appear- 
ance. Many a case of anaemia or rhachitis will be cured by a change 
of such faulty diet. It is better for the baby to develop teeth, bone, 
and muscle on barley or oatmeal and cow's milk and beef-broth than 
to become rotund with ©edematous fat, and anaemic on its mother's 
powerful sympathy and powerless breast-milk. Maternal love does 
not improve the breast-milk of a person with a history of consump- 
tion, rickets, syphilis, nervous disorders, or intense anaemia. Some- 
times even a healthy woman has a milk which is not adapted to that 
particular baby ; then another woman or artificial food must be pre- 
ferred. The addition of barley or oatmeal and beef-soup or beef-tea 
is always advisable when a nursling becomes anaemic without having 
been afflicted with a tangible disease. A small piece of beef, half an 
i^gg daily, a crust of bread, may be added about the end of the first 
year. The diet ought to remain simple and mostly fluid or semi- 
solid until the child is two years old. Prevent bad habits, such as 
fast eating, and enforce regular defecation (not by medication), plenty 
of exercise out of doors, and undisturbed and long sleep in a cool 
room. Avoid crowded school-rooms and protracted lessons. " We 
have laws to protect children from being sent to work in factories 
or to be employed on the stage, but none to protect them from the 
equally destructive, incessant schooling in close rooms, without air 
or exercise. There are too many books bought for Christmas and 
too few skates" (Arch, of Med., February, 1881). 

The subjects of nursing and artificial feeding and of digestive 
organs have been treated of elsewhere ; * therefore I abstain from 

* A. Jacobi, The Intestinal Diseases of Infancy and Childhood, Detroit, 
1887, and in Chapter I. of this book. 



ANAEMIA 117 

discussing the matter here beyond the above fragmentary remarks. 
What cannot, however, be emphasized too much or too often is the 
necessity of resorting to animal food — soups, teas, peptones — in cases 
of infantile anaemia. 

The medicinal treatment of anaemia must fulfil the causal indi- 
cations first. That which depends upon chronic gastric catarrh re- 
quires, according to circumstances, alkalies or hydrochloric acid, 
pepsin, bismuth. Besides the well-known subcarbonate (or sub- 
nitrate), the salicylate has made many friends of late. Pepsin and 
dilute hydrochloric acid are best when combined; a baby of a year 
may take six or eight drops of the latter in six or eight ounces 
of water daily, or the acid may be mixed with milk, according to 
the formula given in a previous chapter. Disease of the kidneys 
has its own indications. The regulation of the heart's action — 
which, when abnormal, is the most frequent cause of habitual epis- 
taxis, and of gastric catarrh and hepatic congestion — is the first 
indication in secondary anaemia. Many a gastric catarrh will not get 
well without digitalis or some other cardiac tonic, and persistent 
nose-bleeding is apt to improve immediately after the administration 
of digitalis, with or without iron. Thus, in a great many cases, 
anaemia is " cured by digitalis." In a similar manner digitalis can 
be utilized for the purpose of more competent oxygenation of the 
blood. When the heart is weak and the lungs, by virtue of old pneu- 
monic infiltrations, offer too great a resistance to an easy circulation 
in the pulmonary vessels, it is again digitalis (or its equivalents) 
which facilitates the extensive contact of the oxygen of the atmos- 
phere with a larger number of blood-cells. 

The insufficient innervation of the muscular tissue of the heart, 
stomach, and the rest, which is one of the most serious results 
of anaemia, is corrected very happily by strychnine or other prepara- 
tions of nux. An infant a year old tolerates and requires one-fortieth 
of a grain of strychnine, or one-third of a minim of the fluid extract 
of nux, daily, for a long time in succession. These preparations may 
easily be combined with any other medicinal administration. 

Iron is looked upon as the sheet-anchor in anaemia. It is mostly 
indicated in cases of primary uncomplicated anaemia. A catarrhal 
stomach does not bear it well ; when, however, the stomach is abnor- 
mal in consequence of the general anaemia, iron improves both the 
general condition and the stomach. In many of these cases the addi- 
tion of bitter tonics is advisable; strychnine is perhaps preferable. 
Anaemia after malaria, dropsy from anaemia and chronic nephritis, 
anaemia with neuralgia, anaemia with (and from) valvular diseases 



Il8 DISEASES OF THE BLOOD AND CONSTITUTION 

which do not result in local congestion, — mainly incompetency of the 
aortic valve, — are greatly benefited by iron. Anaemia after chronic 
diarrhcea requires great care in its use; in most cases it may or 
ought to be avoided. While it is very beneficial in the predisposition 
to hemorrhage, it should be avoided in haemoptysis. It is contra- 
indicated in " inflammatory" fevers, for it increases pulse, arterial 
pressure, and temperature ; but in the more serious infectious fevers, 
such as erysipelas and diphtheria, it is very efficient. It requires good 
digestive powers, which may be stimulated by aromatic tincture of 
rhubarb, tincture of cinchona, or strychnine, and, to combat anaemia 
only, no large doses. The total amount of iron introduced into the 
system in the average daily food does not exceed much a single deci- 
gramme (one and one-half grains), and that contained in the blood 
of the adult has a total weight of three grammes (two scruples) only. 
Still, it is quite possible that the iron introduced into the stomach 
fulfils more indications than that of supplying red blood-cells and 
(to a lesser degree — even that much is doubted — ) haemoglobin. In- 
deed, it sometimes acts as a stomachic. 

Of the preparations mostly in use, either official or otherwise, I 
have mostly employed dialyzed iron, a few minims several times daily, 
the tincture of the malate (pomate), from twelve to thirty minims 
daily, and the same, or somewhat smaller doses, of the tincture of the 
chloride of iron for children from three to eight years of age. The 
dry preparations are the phosphate, from one-half to two grains three 
times a day, and the same doses of the carbonate (saccharated). The 
latter is aptly combined with proper doses of bismuth. The pyro- 
phosphate demands smaller doses. The lactate is a mild and digestible 
preparation which seems not to be appreciated at its full value. 
The citrate of iron and strychnine and that of iron and quinine 
are valuable preparations when the effects of the combinations 
are sought for. Coming with the recommendations of Schmiedeberg, 
ferratin in several daily doses of one or two decigrammes (one and 
a half or three grains) each has been awarded a fair trial; so have 
some other preparations, — the peptonate, the albuminate, the pepto- 
manganate. The obtrusive methods of advertising them do not prove 
their superiority over the drugs and preparations of the Pharma- 
copoeia and of the National Formulary. The syrup of the iodide of 
iron is well tolerated by the youngest infants ; as many drops as the 
baby has months may be given three times a day up to eight or ten 
drops a dose. It is well tolerated by the stomach, in which the iodine 
is freed from the iron and acts as an antifermentative. Besides, 
experience appears to confirm the theoretical inference that it proves 



ANAEMIA 119 

its power as an absorbent in cases of anaemia complicated with glan- 
dular enlargements. The syrup of the hypophosphites cum ferro of 
the Pharmacopoeia may be given in larger doses ; this is the prepara- 
tion which I frequently select when I mean to add arsenic or nux 
vomica in liquid form. It is self-understood that I prefer the legiti- 
mate preparations of the Pharmacopoeia to the wares of the agents 
and advertisers, " physicians' samples" or not. 

Other (animal, like ferratin) preparations of iron are Kobert's 
haemol and haemogallol. It has been suggested, not proved, that 
their animal origin renders them more homogeneous. 

For subcutaneous administration the pyrophosphate of iron with 
sodium citrate, also the albuminated iron, have been recommended; 
also, by Rummo, a ten-per-cent. watery solution of the ammoniated 
iron citrate, and by Lepine, one of a two-and-a-half-per-cent. solu- 
tion subcutaneously. As anaemia is a chronic condition which re- 
quires " chronic" treatment, and the injections cause pain and indu- 
rations, it is not very probable that this mode of employing the 
remedy is available. 

The administration of iron appears to have an indirect effect also, 
which is apt to do much good. As a rule, the inhalation of oxygen 
gas, continued for five or ten minutes, at intervals of from an hour 
to two hours, seems to improve sanguification and metamorphosis 
considerably. This wholesome action, it always seemed to me, was 
most perceptible while iron was administered. To admit oxygen red 
blood-corpuscles are required; it appears that the influence of iron 
on their organization and numbers renders the introduction of oxygen 
into the blood easier and more beneficial. Ox}^gen was often credited 
with being a general tonic, and its inhalation was considered at one 
time almost a panacea. So long as the organs of respiration and 
circulation are normal, the atmospheric air contains more than they 
require. Still, whenever they are disordered, in the orthopnoea of 
pneumonia, in asthma and emphysema, in pulmonary tuberculosis, 
in cardiac diseases (as also in poisoning with carbon oxide or when 
there is methaemoglobin in the circulation), and in anaemia depending 
on these conditions, the inhalation of oxygen is of undoubted service. 
It has the advantage of being readily prepared pure; that is more 
than we can say of ozone (p. 74). 

Some of the worst forms of anaemia are greatly benefited by arsenic. 
They are those which result from long-continued inanition and slow 
convalescence, in which the stomach does not suffer primarily; from 
primary catarrh; from chronic malaria; from chronic tuberculosis 
of the lungs ; from chronic glandular swellings of a malignant type, 



120 DISEASES OF THE BLOOD AND CONSTITUTION 

either lymphoma or sarcoma or adenoma. In all of these forms it 
is highly useful. The doses need not be large, but may be increased 
slowly. One-one-hundredth of a grain of arsenous acid, or one drop, 
or one and a half of Fowler's solution, three times a day, after meals, 
the latter amply diluted, are well borne for weeks, even months, with- 
out interruption, by a child of four or five years. In malaria the 
remedy may be given with quinine (and iron), in exceptional cases 
with ergot, in other forms with strychnine (and iron) ; in pulmonary 
tuberculosis with digitalis. 

The gradual increase of the doses of arsenic may be effected in 
the following manner. A drachm of Fowler's solution is diluted with 
sixty drachms of water ; three doses of this mixture are given daily. 
If the initial dose is to be one drop, give a teaspoonful; the next 
dose is a teaspoonful -f one drop, the third dose a teaspoonful + two 
drops, and so on, until the sixty-first dose consists of a teaspoonful 
and sixty drops. Thus the original dose is gently and slowly doubled 
in twenty days. 

Children bear arsenic better than adults and very much better 
than senile patients. Still, even they must not take it when they are 
affected with gastric disorders ; nor continue it when in the course 
of treatment conjunctivitis, oedema of the eyelids and face, or diar- 
rhoea makes its appearance. A modern preparation, the cacodylate, 
appears to offer no advantages over any of the rest. Sometimes, when 
Fowler's solution (liquor potassii arsenitis) is not well tolerated, the 
sodium preparation of the Pharmacopoeia (Pearson's solution) may 
be tried in tenfold doses, or arsenous acid, alone or in combinations, 
in doses of one milligramme (one-sixtieth of a grain) daily to a child 
of two years or older. 

Among the important remedies in anaemia change of place should 
be mentioned, — from city to country, from lowland to altitudes and 
woodland. Friction with cold water and after a while cold bathing- 
will improve cutaneous and general circulation and sanguification. 
Mineral springs with iron and carbonic acid, so frequent in Germany 
and France, enjoy a well-deserved reputation. 

This dietetic and medicinal treatment, mostly so effective in sim- 
ple anaemias, is also indicated in chlorosis when it develops in chil- 
dren. In them the anatomical cause giving rise to life-long chlorosis 
—viz., persistence of the foetal smallness of the aorta (Virchow) with 
smallness of the general arterial system — cannot be wholly overcome. 
It is here that bitter tonics should be added from time to time to 
the preparations of iron and digitalis to stimulate arterial and cardiac 
action. Both of these require the continued use of cold water, — viz., 



CHLOROSIS. PERNICIOUS ANAEMIA 121 

daily washing or bathing with vigorous rubbing, followed by sea- 
bathing, and systematic exercise, gradually increased. The diminu- 
tion of haemoglobin, while the number and character of the red blood- 
cells are more or less normal, requires ample and cautious feeding; 
it is here that peptones to such an extent as can be absorbed are indi- 
cated. It should never be forgotten, however, that all the symptoms 
of chlorosis in a child (as in the grown woman) may be caused by 
undiscovered malignant tumors, or by gastric ulcerations (not so 
very uncommon), or by duodenal ulcerations, with slow and almost 
imperceptible hemorrhages. It may be complicated and increased 
(caused, according to some) by intestinal disorders leading to con- 
stipation and autoinfection, or by enteroptosis. These disorders have 
their own indications, which may be studied under the proper head- 
ings. In such cases iron and arsenic will be combined with alkalies, 
with mild purgatives and antifermentatives, or with proper bandaging. 
Nowhere more than in chlorosis should a sojourn in higher altitudes 
be recommended; the red blood-cells increase with rising altitudes. 
Christiania yields 4,970,000, Berlin (fifty metres) 4,647,000, Gorbers- 
dorf (five hundred and sixty-one metres) 5,800,000, Schoneberg 
(six hundred and fifty metres) 5,887,500, Reiboldsgrun (seven hun- 
dred metres) 5,970,000, and Davos (fifteen hundred and sixty metres) 
6,551,000 blood-cells in the cubic millimetre.* 

The tendency to dilatation and hypertrophy of the heart may be 
transitory only, but small doses of digitalis should be given a long- 
time. The same treatment is indicated when there is a tendency to 
thrombosis in peripheral veins. The treatment of very bad cases may 
begin with absolute rest in bed and generous feeding. 

Pernicious (essential) ancemia is characterized by a decrease of 
red blood-cells (from four or five millions in a cubic millimetre to 
one or even one-half of a million), which, moreover, exhibit irregular 
sizes and shapes (poikilo-, micro-, and megalocytes, not absolutely 
characteristic, however), while haemoglobin is not reduced at the 
same rate. When it is caused by atrophy of the peptic glands (Kinni- 
cutt), or prolonged icterus, prolonged gastro-intestinal disorders, 
protracted suppuration, infectious fevers, or syphilis, or entozoa 
(ascaris, taenia, bothriocephalus), the indications are clear. Many 

* The number of erythrocytes is also increased, but haemoglobin diminished, 
in Ancemia montana, mountain anaemia (mal de la puna), the result of 
sudden exposure to high altitudes, with palpitation, suffocation, fainting, and 
hemorrhages from the mouth and nose. Thus it is the exact reverse of 
pernicious anaemia. Its indication is clearly removal from the high altitude 
which caused it. 



122 DISEASES OF THE BLOOD AND CONSTITUTION 

such cases get well when treated for known causes. That is why 
every addition to etiology is so welcome. That is why William Elder 
could report the case of a man of thirty-five years whom he treated 
successfully with eighteen injections, one every other day, of ten 
cubic centimetres of antistreptococcus serum, and why there is quite 
an array of cases getting well with anthelmintic treatment. Ewald 
has found atrophy of the small intestines in many cases of pernicious 
anaemia (indican? toxaemia?). Knud Faber published a case (Berl. 
klin. Woch., July 26, 1897) which seems to prove its connection with 
a stricture of the small intestine. If a diagnosis could have been made 
in his case it is possible that an operation would have prevented 
anaemia. As other such strictures (tubercular, syphilitic), quoted 
by him, are also known to have been connected with intense anaemia, 
the suspicion is justified that an intestinal toxin caused or occasioned 
by them (as also by apepsia and helminthes) is the source of the 
rapid destruction of blood-cells and the cause of pernicious anaemia. 
If that be so, intestinal antisepsis, if it is ever accomplished to a 
sufficient degree, will cure many a case. Of the remedies mentioned 
above, arsenic in rising doses is quite effective ; iron and small doses 
of quinine act as adjuvants; bone-marrow (when raw or boiled, it 
nauseates quickly) or its preparations (Armour's or others), the daily 
doses of which may vary from one-half of one to two teaspoonfuls 
or more, have been credited with good effect. I have seen improve- 
ment, but no cure. Weir Mitchell's rest and feeding cure, with gen- 
eral massage, benefited some. The capricious appetite prefers mostly 
a vegetable diet, the failing digestion requires stimulants (strychnine), 
besides pepsin with hydrochloric acid; the absence of blood-cells and 
the consequent inability to bind oxygen and to produce heat demand 
warm clothing and warm rooms ; diarrhoea, its symptomatic treat- 
ment; and utter debility and collapse, infusion of salt water. In 
spite of the lack of erythrocytes, combined with shallow respiratory 
movements, the systematic inhalation of oxygen should be tried. An 
undoubted case of pernicious anaemia from no tangible cause in a 
child less than a year old I saw in Boston with Rotch and Dr. Ladd. 
She bore little iron and no arsenic, but got entirely well. 

The prognosis of leucocythczmia (leukcemia) , no matter whether 
lymphatic or splenic, is still worse than that of pernicious anaemia. 
From the latter it is diagnosticated by the increase of leucocytes 
( 1 to 50 to 1, instead of 1 to 250 or 500) and of eosinophile cells. 
Acute cases have been observed after influenza and pernicious anaemia. 
They lasted a week only, or longer ; in its usual protracted form it is 
known to follow malaria, influenza, syphilis, glandular, intestinal, and 



LEUCOCYTHEMIA. PSEUDOLEUKEMIA 123 

blood anomalies. Klebs and others, besides a case that came under 
my observation, saw cases in the new-born, with ascites (leucocytes 
529,000, erythrocytes 4,000,000). Complications are frequent, rare 
with diabetes and bone diseases ; and prevention is therefore a possi- 
bility. Albuminoids in blood and tissues are rapidly destroyed ; there- 
fore albuminoids in every possible shape, peptones, albumoses, etc., 
should be given in absorbable quantities. Rest, massage, cold and 
heat, transfusions, infusions, oxygen inhalations, arsenic and iron, 
quinine, bone-marrow, injections of ergotin into the subcutaneous 
tissue, of arsenic into the spleen, electricity and galvanism, extirpation 
of the spleen (always fatal — should be performed early, if at all), 
treatment of the accompanying hemorrhage, of perspiration, of pleu- 
ritis, and of ascites, — all are in vain. I know of no authentic case, 
either acute or chronic, that recovered. 

Pseudoleukemia (Hodgkin's disease), though there are so many 
transformations of this form of anaemia into leucocythaemia as to 
make a common origin (infection?) and nature very probable, has 
in most cases its own symptomatology (painless, swelled lymph-bodies 
from the neck down all over the body, swelled tonsils, liver, and 
spleen, no leukemic blood, merely leucocytosis). In its history rha- 
chitis, traumata, or intestinal disorders are mentioned frequently. 
The swelling is not a simple hyperplasia (Dorothy M. Reed in Johns 
Hopk. Hosp. Rep., vol. x., 1902), but a change suggesting a chronic 
inflammatory process, proliferation of endothelial and reticular cells, 
formation of lymphoid and of characteristic giant cells, gradual in- 
crease of connective tissue leading to fibrosis, and in most many 
eosinophiles (absent in tuberculosis, sarcoma, and lymphatic leukae- 
mia), with occasional hemorrhages, and ascites now and then, the 
latter sometimes without cirrhosis of the liver. The diagnosis from 
general sarcomatosis, which causes inflammatory adhesions between 
the lymph -bodies (isolated in pseudoleukemia), is not always easy. 
Arsenic is again the sheet-anchor. Piperin, from five to fifty centi- 
grammes or more daily (one to ten grains), has been recommended. 
Berberin sulphate seems to deserve credit in repeated daily doses of 
one-sixth of a grain (0.01) ; it certainly stops the troublesome con- 
stipation, but should not be given in such doses as to cause diarrhoea. 
It seems to improve the appetite and to reduce the size of the glands 
and of the large viscera. 

Splenic anceinia, with its large spleen and somewhat swelled liver, 
no leucocytosis, but poikilocytosis, occasional megaloblasts, some 
diminution of haemoglobin, and some nucleated blood-cells, does not 
deserve a place of its own in our nomenclature, unless the original 



124 



DISEASES OF THE BLOOD AND CONSTITUTION 



swelling of the spleen (with atrophy and sclerosis of the Malpighian 
bodies) be claimed as the cause of anaemia. It shares the therapeu- 
tical indications of its sister anaemias, which are harmless and fairly 
useless. But the removal of the spleen has been quite successful, so 
that it should always be advised and no other chances taken. But 
first be sure of your diagnosis. The nomenclature of hypertrophy 
of the spleen with cirrhosis of the liver and ascites has been unneces- 
sarily saddled with a new name, that of Banti. 

2. Rhachitis. 

Many cases of rhachitis which depend on hereditary influences 
might have been prevented or modified by attending to the parents 
before conception or to the mother during pregnancy. I have known 
women to bear healthy or rhachitical children according to the con- 
dition of health or ill health during the year preceding parturition. 
A number of their constitutional ailments, such as anaemia, tuber- 
culosis, and syphilis, make their appearance in the offspring with the 
symptoms of rhachitis. If that precaution have been neglected, the 
injury inflicted upon the infant cannot be completely annulled; in 
many cases, however, it can be greatly moderated. Thus there are a 
great many cases of early rhachitis which are due to the influence 
of mitigated syphilis in the parents. Indeed, some of the microscopical 
bone lesions of the two diseases, as they are met with in the newly- 
born, are difficult, some impossible, to distinguish from one another. 
Such cases can be greatly benefited by an antisyphilitic (mercurial) 
treatment, which should be continued through a period of many 
months. 

Attention should be paid to general hygiene. More can be accom- 
plished by furnishing good air than by any other means. The air 
of the winter is no contraindication to keeping windows open and 
to taking the young baby out so long as there is ample clothing and 
covering. Sea-air is preferable so long as there is no contraindication, 
for instance, in the condition of the respiratory organs. 

Sojourning in the country is beneficial only when the rhachitical 
infant is not locked up in the house. Sea-air, together with sea- 
bathing, warm, cool, or cold, according to age, condition, and train- 
ing, is an excellent preventive and curative measure. England com- 
menced that practice on a large scale in 1750; Italy, France, Germany, 
and America twenty-five years ago. The sea-hospitals have done an 
immense amount of good. To eradicate rhachitis, however, the chil- 
dren must be kept at the shore for years. In America we are always 
too much in a hurry, and expect the benefits of heaven and earth in a 



RHACHITIS 125 

particle of a season. When no sea-shore is accessible, the bathing in 
salt water, with friction, massage, occasionally with electricity, may 
be done at home. When eczema is caused by it, the salt-water treat- 
ment should be discontinued. 

Plenty of air by day and by night, coupled with poor food, is still 
safer than the best possible food with bad air. Comby's saying, that 
rhachitis gets access through the stomach, not through the skin or 
lungs, requires a good deal of modification. Still, the nature of the 
food is highly important. Lactation must not be continued beyond 
the appearance of two or four teeth. A wet-nurse should not be too 
young nor too old. But, after all, even an apparently proper age or 
condition of the mother or the wet-nurse does not always exclude 
the possibility of a breast-fed baby becoming rhachitic. In such a 
case a well-selected artificial food is preferable to breast-milk. Pure 
cow's milk, when given as exclusive food, no matter whether raw 
or boiled, is harmful. The reason for this warning has been discussed 
in Chapter I. In addition, I will again refer to my criticism on the 
excess of lactic acid (milk-sugar) in the infant's alimentary canal. 
Excess of lactic acid appears to have detrimental effects on the nutri- 
tion to such an extent that rickets has been explained by its chemical 
action. Like acetic, oxalic, and formic acids, lactic acid has been 
claimed as the cause of rhachitis by Ch. Heitzmann, in 1873 ; Tripier, 
in 1875; Neiss, in 1876; Siedamgrotzky and Hofmeister, in 1879, 
while Albarel could not verify their observations. Such differences 
had been noticed before. Schmidt and O. Weber long ago found 
lactic acid in the bones of animals fed on that material ; Marchand 
and Gorup-Besanez in the urine ; while Virchow and Lehmann found 
the bones and the blood alkaline. After all, however, it should be 
remembered that rhachitis means more than merely excessive elimina- 
tion of lime by the kidneys and intestines ; its pathology is not com- 
plete without the soft swelling of the peri-epiphyseal cartilage, of 
the epiphyses, and of the periosteum, also deformities of the bones. 
That is why lactic acid in the circulation should not be accused of 
being the cause of rhachitis. But this much is certain, that by an 
undue presence of lactic acid the amount of phosphate of lime in 
the urine and in the faeces, at least in one of them, is at once vastly 
increased and that the bones are deprived of part of their calcium.* 
Artificial foods must be well selected and watched. The absence of 



* It is on account of this and its eliminative, chemical action on lime (and 
thereby diuretic effect), which it removes in the shape of salts, that Rumpf 
gives lactic acid in those cases of angina pectoris which depend on calcification 



126 DISEASES OF THE BLOOD AND CONSTITUTION 

pathogenic germs from them is not the only safeguard. Even 
Rotch's modified milk and Gaertner's fat milk do not protect against 
rhachitis, though they be fairly proof against microbes. The addi- 
tion at an early date of cereal decoctions, barley, oatmeal, and of 
animal broths renders all the known milk preparations safer and 
more wholesome. Too large a percentage of fat in the foods of young 
infants should be avoided. The addition of fat is not always a pro- 
tection against rhachitis, and may easily be overdone. Diarrhoea, 
dyspepsia, from whatever cause, and constipation should be corrected, 
and the warning often expressed by me and urged by Comby should 
not be forgotten, that over-alimentation is at least as dangerous as 
under-alimentation. That the skin requires intelligent attention was 
suggested above. Whether a bath should be given immediately after 
birth and continued regularly during the first weeks ought to depend 
on the nature of the individual case. As a general rule, which is valid 
for every child, bathing — first tepid, later cooler, in salt water when 
there appears to be an indication for more surface stimulation, with 
appropriate friction — improves both the cutaneous and the general 
circulation. 

Rhachitis due to, or connected with, digestive disorders demands 
the correction of the latter. Gastric catarrh is not frequently primary ; 
more commonly it is the consequence of a faulty diet ; but in both cases 
it is the cause of anaemia, and either of insufficient or of abnormal 
secretion of both the mucous membranes and the glands. The gas- 
tric catarrh of rhachitis is pre-eminently acid ; thus, neutralization of 
the stomach is often required before every meal and between meals. 
Prepared chalk, calcined magnesia, sodium bicarbonate, and the sev- 
eral preparations of bismuth find their proper indications in this con- 
dition. Bismuth salicylate, animal carbon, and resorcin find their 
places, besides aromatic teas, in complications with fermentative pro- 
cesses in the intestine and excessive flatulency. When the secretions 
of the stomach are merely insufficient, the addition of sodium chloride 
in proper quantities will facilitate the formation of hydrochloric acid. 
When that plan does not suffice, pepsin and muriatic acid, the latter 
largely diluted, will take the place of the physiological gastric juice ; 
and bitter tonics and alcoholic stimulants, also diluted, will stimulate 
a normal secretion. Still, the selection of a proper food forms the 



of the blood-vessels, about fifteen grammes daily for months in succession. It 
is self-understood that the food should be fairly free of lime. That is why 
the diet is as follows: 250.0 meat, 100.0 bread, 100.0 fish, 100.0 potato, 100.0 
apples (or instead, green beans, peas, or cucumbers). 



RHACHITIS 127 

main part of the indications. The principles of infant feeding, both 
in health and disease, I have laid down in the first part of this book ; 
to that I refer; also to my suggestions, in the same place, on the 
selection of animal foods so urgently required in rhachitis (p. 43). 

Cod-liver oil, when tolerated, influences rhachitis favorably. As 
a rule, however, it is not so universally well borne in rhachitis as it 
is in " scrofula." I do not advise the use of its compounds, emulsions, 
and so on, except when it is disliked or the latter have some other 
indications, for instance, diarrhoea; this is sometimes produced by 
the oil, mainly in the hot season. In that case the remedy may have 
to be discontinued, or may require the temporary addition of bismuth 
subcarbonate or calcium phosphate. The action of cod-liver oil is 
considered by some hygienic only, by others remedial. The former 
attribute its effects to the fat, and believe the substitution of any 
assimilable fat an equivalent. As I said before, I do not believe its 
agency to be thus restricted, for three teaspoonfuls of cod-liver oil 
will never be replaced by three teaspoonfuls of cream or other fat. 
Universal experience teaches its wholesome influence in many morbid 
tissue-changes. Possibly the mystery of its action is best explained 
by attributing to it a percentage, though ever so slight, of some organic 
tissue juice of a nature and efficacy to be compared with that of the 
ductless glands. Tempted by that point of view, Heubner tried the 
action of thyroid gland in rhachitis, but without any tangible effect. 
He believes, however, that the general condition of the infants was 
improved by it. 

Malt and " maltine" preparations have found favor both with the 
profession and the public. Unfortunately, the market has been 
swamped with all sorts of combinations and mixtures to such an 
extent as to shake confidence in their honest composition in the same 
degree as the mere object of making money by them becomes pre- 
eminently clear. The preparation ordered by the United States 
Pharmacopoeia should be preferred. 

Though rhachitis be a general disease, and not merely one of the 
osseous system, the anomalies exhibited by the bones are apt to 
attract most attention. The changes exhibited in the shape of the 
chest, which result from the pressure of the atmosphere on the soft 
rhachitical ribs, are not liable to disappear entirely. The " pigeon- 
breast" — that is, the prominence of the sternum and (or) the costo- 
cartilaginous junctures — remains for life to a greater or less degree, 
according to the severity of the affection or to the restoring power 
of the expanding lungs. It requires early medical and surgical in- 
terference and protracted gymnastic exercise. Even crying is wel- 



128 DISEASES OF THE BLOOD AND CONSTITUTION 

come, and in children of two or three years trumpet-blowing, soap- 
bubbling, etc. The curvatures of the diaphyses of the long bones 
are apt to be less marked in the adult because of the extension 
which takes place during growth. If ever splints are to do any good 
they should be applied before the bones have become hard again ; 
the eburnation following the softness of the bones after recovery 
resists every degree of permissible pressure. The tendency to flat- 
foot, acquired through the flabbiness of the ligamentous apparatus 
during the attempts of the child at locomotion, requires massage and 
sustaining by a shoe made strong enough to support the ankle and 
a steel spring just sufficiently strong to restore the arch of the foot ; 
scoliosis, a Sayre's plaster-of-Paris or a felt jacket; the rhachitical 
groove round and above the insertion of the diaphragm, well-directed 
gymnastics of the chest ; inflexible and ugly curvatures of the long 
bones, either osteoclasy (fracturing of the curved bone while leaving 
the periosteum intact, and resetting) or osteotomy (straightening 
the bone after it has undergone a cutting operation). Of these two, 
osteoclasy was the only operation resorted to formerly. The fracture 
of the bones was either manual or instrumental, mostly successful in 
the middle of the femur or tibia, mostly unsuccessful for genu valgum 
or varum, inasmuch as it often tore off the epiphysis, or fractured in 
an undesirable place, and was sometimes followed by septicaemia. 

Osteoclasy has been mostly replaced by osteotomy. It is a simple 
and open operation. It is seldom required on the upper extremity, 
generally on the lower, not so often on the thigh as for genu valgum 
and varum or for the curvatures of diaphyses. The genu valgum 
of children results from the curvature both of the femur — usually 
the only one at fault in adolescents — and of the tibia. It requires the 
supracondylar operation of Macewen, and often a supplementary 
operation on the tibia. The curvature of the tibia has mostly its con- 
cavity interiorly and posteriorly, and is usually found at its lower 
half. The operation may be either simply linear, transverse or oblique, 
or cuneiform (wedge-shaped). In bad cases the latter is preferred, 
and not seldom a single operation is insufficient. An interval of a few 
weeks is ample between the several operations that may become neces- 
sary. The results of osteotomy are almost always absolutely good. 
Suppurations are not frequent and are controllable. 

During the active rhachitical process the bones will not only bend, 
but are liable to be changed in their continuity. It is true that 
genuine fractures are not very frequent because of the softness of 
the bones and the succulence of the periosteum. But infractions 
(green-stick fractures) are quite common about the extremities and 



RHACHITIS. CRANIOTABES 



129 



clavicles. The periosteum never participates in the injury; the bone 
is more or less bent upon itself; the ends are not entirely separated 
and are easily readjusted, but require splinting until the rhachitical 
process has terminated in general recovery. Immobilization of the 
entire body is sometimes required when the tendency to infraction is 
quite extensive. 

Many of the serious results of softness of the bones could be 
avoided or mitigated by precautionary measures. Babies in general, 
and those with incipient rhachitis in particular, must not be made 
to sit up before their vertebral columns and their dorsal muscles are 
able to support them. They must not be carried about in an erect 
posture, nor on the same arm always; the latter practice is an in- 
variable cause of scoliosis, and frequently of genu valgum of one side 
and of genu varum of the other. They must be kept and carried about 
in a reclining posture; better on a hair pillow than on the arm until 
they feel strong enough to do without it. Thus scoliosis can be pre- 
vented. They must be discouraged to walk before their limbs are 
sufficiently strengthened; no walking baskets should be employed, 
no fond and proud grandparents allowed about; thus the curvatures 
of the diaphyses of the lower extremities, which in part result from 
the vertical weight of the body on the feeble limbs and the secondary 
deformities of the pelvis, are reduced to a minimum. 

Craniotabes, the rhachitical softening of the cranial bones, is one 
of the earliest symptoms of the disease. The bones which commenced 
their postnatal ossification in a normal manner begin to soften to 
such an extent that the parietal and occipital bones exhibit a number of 
spots in which the osseous tissue has nearly or entirely disappeared. 
The hair falls out in that neighborhood, the scalp is perspiring copi- 
ously, the veins are dilated, the bones and meninges become hyper^emic, 
and meningeal effusions are quite frequent. The softness of the bones 
results in asymmetry of the cranium, which is flattened by the slight 
pressure of a soft pillow. This asymmetry is liable to disappear after 
recovery, except in grave cases. 

The local hyperemia and excessive occipital heat forbid the use 
of warm bonnets and feather pillows. A soft hair pillow must be 
so arranged that the head, together with the body, can be comfortably 
carried without any pressure. Elsaesser (1843) recommended a pil- 
low with a central depression or perforation ; a small air-cushion 
rilled to one-third of its capacity is very acceptable. Consecutive brain 
symptoms require appropriate treatment. Great convulsibility de- 
mands bromides, chloral, and mild opiates, which are well tolerated 
ui this condition. The perspiration requires cooling with water, or 

9 



l 3 o DISEASES OF THE BLOOD AND CONSTITUTION 

water and vinegar, or powdering with one part of salicylic acid mixed 
with ten parts of zinc oxide and twenty-five of starch. The gen- 
eral treatment of rhachitis improves this local cranial symptom, which 
is quite serious. In former years I was in the habit of giving a 
good prognosis, provided the next six or eight weeks passed without 
fatal symptoms (convulsions, etc.). That period was generally suffi- 
cient to so change both the general nutrition and the local condition 
as to restore a fair average of health both in the cranium and its 
contents. The experience of late years has shortened this period. 
What I suggested in a brief paper on the use of phosphorus in the 
treatment of chronic and subacute diseases of the bones in the Trans- 
actions of the Medical Society of the State of Nezv York, of 1880, 
and in a paper on anaemia in infancy and childhood read before 
the Medical Society of the County of New York in 1880 (Arch, of 
Med., February, 1881), has proved a great success in other hands. 
For it is to Kassowitz that the credit of the introduction of phosphorus 
as the principal remedy in rhachitis is mainly due. When, thirty 
years ago, C. Wegner fractured the bones of rabbits and fed the 
animals on minute doses of phosphorus, he found that these bones 
would heal in a much shorter time than those which were not so 
supplied. This observation induced me to employ the drug in all 
cases of (mostly tuberculous) subacute and chronic osteitis, Pott's 
disease, and caries of the tarsus ; and a great many cases led me to 
conclude that recovery was more readily accomplished under this 
treatment. Phosphorus is, by virtue of its irritating effect, when given 
in small doses, a tissue-builder (Kassowitz asserts that it impedes 
the formation of blood-vessels), when in large doses, a tissue- 
destroyer. In the former it in part acts through the rapid develop- 
ment of connective tissue, similarly to what Lannelongue expects to 
attain by the local injections of zinc chloride solutions near tuber- 
cular joints. Thus I became convinced of its tissue-building prop- 
erties in other parts also. I may mention here, before I have an 
opportunity to return to the subject in extenso, that I have availed 
myself of this quality of phosphorus for other purposes. It has 
served me well in many ominous cases of purpura and similar pro- 
cesses, in which a congenital or acquired ill nutrition of the blood- 
vessel walls results in habitual hemorrhages. 

Kassowitz's results with the use of phosphorus in rhachitis are 
generally good. The cases in which it has rendered me its best 
services are exactly those alluded to, of craniotabes. A very few 
weeks suffice to change the condition of the cranial bones considerably ; 
the softened parts become smaller and harder and the consecutive 



RHACHITIS. PHOSPHORUS 13 1 

symptoms milder. It is of equal value in acute rhachitis, with its 
extensive acute epiphysitis, rapid pulse, diarrhoea, general feebleness, 
and (frequently) some symptoms of scurvy. 

The dose of phosphorus in these cases is from one-third to one- 
half of a milligramme three times or twice a day. The oleum 
phosphoratum of the U. S. Pharmacopoeia contains one part of 
phosphorus in ten parts of ether and ninety of oil. Its daily dose is 
from two to three minims. Concentrated oil solutions are liable to 
decompose. " Thomson's solution" keeps fairly well, but the best 
preparation is the elixir of phosphorus of the U. S. Pharmacopoeia, 
composed of 210 parts of the spirit of phosphorus, 2 parts of oil of 
anise, 550 parts of glycerin, and a sufficient quantity of aromatic elixir 
to make 1000 parts. Of this elixir a teaspoonful contains one milli- 
gramme of phosphorus, and a dose, to be repeated three times a day, 
is from six to fifteen minims. No temptation ought to be strong 
enough to employ phosphates, which will invariably reappear both 
in the urine and in the faeces. It seems probable, moreover, that the 
phosphates when contained in nutriment are more digestible and more 
assimilable than when given as a medicine, but only when given in 
organic combination like that in which they are in human but not 
in cow's milk, which has much more of it, but in an insoluble and 
unabsorbable condition. It is probable that the preparation of cow's 
milk with hydrochloric acid (p. 34) will keep lime in better solu- 
tion. Its place may even be taken by extra doses of sodium chloride, 
with its tendency to change into hydrochloric acid (p. 14). It is 
worth while here to refer to the observation of E. Pfeiffer, who found 
that the breast-milk of mothers who had rhachitic infants contained 
only 0.1 per cent, of chloride of lime (altogether less lime than nor- 
mal), and of Zweifel, who reports that nearly all the infants in 
workingmen's families were rhachitic for the reason that the bread 
(in Saxony) is made without salt, and that on that account nursing 
women had less than the normal quantity of salt in their milk. 
Another plea for the copious use of salt ! Phosphates are much 
inferior in effect to the hypophosphites of the Pharmacopoeia with 
or without iron. Phosphorus given simultaneously with cod-liver 
oil is a good combination, but it is a doubtful practice, so long as 
the latter is not a uniform compound, to dissolve phosphorus in the 
oil. No danger need be feared from the administration of phos- 
phorus, for the doses are small and may be continued a long time. 
Indeed, phosphorus poisoning is not observed in the lower oxida- 
tions and not in organic combinations. When anaemia is intense, 
the preparations of iron are required. Besides the above, the syrup 



I 3 2 DISEASES OF THE BLOOD AND CONSTITUTION 

of the iodide of iron may be given, as many drops three times a day 
as the baby is months old, or from ten to twenty-five drops three 
times a day to children of from one to two or three years. When the 
spleen and also the lymph-bodies are very large, three daily doses of 
from one-half to one drop of Fowler's solution are beneficial. In 
scorbutic cases or complications, fruit-juices are required. Heubner's 
experience with phosphorus in bad hospital cases is negative. The 
famous teacher knows, however, that bad rhachitis never does well in 
hospitals. If it requires anything, it is air, air, and again air ! To his 
discomfiture, however, we owe some observations which, though they 
be negative, are valuable. Guided by what he takes to be a fact, that 
all irritations and inflammations from known causes are local, and 
by Lanz, who finds certain relations between the thyroid and bone 
development, and suggests a trial of thyroid in rhachitis, he gave 
from one-half to one decigramme of Merck's thyroidin every other 
day, or every day, with a negative result so far as improvement of 
rhachitis was concerned; with a favorable effect, however, he be- 
lieved, on the general condition of the child. 

Laryngismus stridulus, the crowing inspiration of infants, is al- 
most always connected with craniotabes, and caused by its meningeal 
and encephalic results. It consists of two stages, the first of which 
is that of paralytic apncea, the second of a long-drawn and loud 
inspiration through the spastically contracted glottis. The causal 
treatment is that of rhachitis in general, of cranial rhachitis in par- 
ticular. Before, however, it can accomplish a permanent effect the 
single attacks of, and the general tendency to, laryngismus require 
attention. For any attack may prove fatal, though the assertion of 
Vogel, who expresses the opinion that most cases of laryngismus 
are fatal, is grossly exaggerated, in my opinion, which has not changed 
in this respect since my utterances in 1871.* Besides phosphorus, 
syrup of the iodide of iron, and other treatment, constipation requires 
more than the usual attention, for the nerve-equilibrium is easily 
disturbed by a slight irregularity in any of the organic functions. 
To soothe its general vulnerability the regular administration of the 
bromides (twelve or fifteen grains daily of a mixture of potassium, 
sodium, and ammonium salts) or of a few grains daily of zinc valeri- 
anate is indicated. Many cases bear one-sixth of a grain of codeine 
in the twenty-four hours. These cases of excessive irritability are 
quite precarious. In them the ears require particular attention, for 
the slightest (external or) internal otitis is liable to produce con- 



* American Journal of Obstetrics. 



RHACHITIS. LARYNGISMUS 



133 



vulsions. In them even the lancing of gums, when there is but a 
suspicion of local pruritus, may become pardonable. The attack can 
be cut short by shaking the infant, or slapping the face with a cloth 
dipped in water, or using the spark of a Leyden flask (for there is no 
time for the administration of the interrupted current). General con- 
vulsions, which are not uncommon after an attack, require the inhala- 
tion of chloroform or the rectal injection of from four to eight grains 
of chloral hydrate.* 

The rhachitical disorders of the respiratory organs owe their 
origin to several causes. In rhachitis the heart is of average size, 
but the arteries are abnormally large. Great width of arteries lowers 
the blood-pressure. That is why the muscles and bones suffer from 
insufficient nutrition, and why the circulation in the respiratory organs 
is slow and sluggish, with a tendency to produce congestion and 
catarrh. Other causes of the chronic bronchial catarrh of the rha- 
chitic infant, which is so apt to become bronchitis and terminate in 
broncho-pneumonia, depend upon the smallness, particularly of the 
lower half, of the contracted chest, which compresses the lungs and 
the heart, mainly when the elliptic shape of the chest is changed into 
the quadrangular or triangular; and the tumefaction of tracheal, 
bronchial, and mediastinal lymph-bodies, which are in close lymph com- 
munication with the bronchial mucous membranes. There are but 
few thoroughly developed cases of rhachitis, when complicated with 
bronchitis, without them. Not infrequently some of them can be felt 
in the supraclavicular spaces ; more commonly they can be percussed 
behind and to the left of the manubrium sterni, the dulness of which 
is in many cases but partly thymic. Sometimes they are discovered 
by percussion of the infraclavicular region of the (right or more 
frequently the) left side and often on the left side of the intra- 
scapular region. These glandular swellings, which point to and ex- 
plain the frequent relations of rhachitis, scrofula, and tuberculosis 
with one another, are not uncommon appearances in the autopsies of 
rhachitical babies who finally died of the last developments of their 
chronic catarrh. 

This tendency to glandular swellings requires early attention. 
It is here that cod-liver oil and the syrup of the iodide of iron are 

* There are occasionally other causes, independent or contributing, of 
laryngismus which may be mentioned here, — viz., enlarged thymus, swelled 
bronchial glands, adenoids, and extra-cerebral nerve disturbances (inferior 
laryngeal), the latter two mostly depending on one or both of the first named. 
They have their own indications, but will hardly ever be found without 
rhachitis. 



134 



DISEASES OF THE BLOOD AND CONSTITUTION 



mainly serviceable. In many cases the addition of half a minim of 
Fowler's solution, administered three times a day, proves beneficial. 
This is the condition of things in which cold sponging, salt-water 
bathing, and salt air are particularly beneficial. Out-door life must 
be insisted upon, and there are but few reasons — mostly of a local 
character — which forbid such babies to enjoy fresh air at all hours 
of the day and night. 

Subacute or acute inflammations of the respiratory organs, when 
they have made their appearance during the chronic rhachitic catarrh, 
require, besides the usual rational treatment, some additional meas- 
ures. More care than in an average case of the otherwise healthy 
must be taken lest the faltering strength be exhausted before the 
acute disease has had time to run its course. The sluggish circulation, 
depending on general debility and the large size of the arteries, de- 
mands the administration of heart tonics — digitalis, strophanthus, 
sparteine, caffeine, or coffee — from the very beginning, and besides 
small doses of alcoholic stimulants at an early stage or the use 
of stimulant expectorants, such as ammonium carbonate or cam- 
phor. There is a positive contraindication to antimonials and squill ; 
even ipecac must be avoided because of its possibly depressing 
effect. 

Rhachitic constipation is mostly due to the incompetency of the 
muscular layers of the intestine and of the abdominal wall. Thus 
purgatives must be avoided in its treatment, with the exception of 
those cases in which the accumulation of faeces in the bowels is 
attended by serious consequences. In these an occasional dose of 
calomel will act both as a laxative and a disinfectant. When an 
acid gastric catarrh accompanies the intestinal weakness, calcined 
magnesia in doses of a grain, given on an empty stomach or before 
meals (never after), repeated several times daily, will neutralize the 
abnormal acidity of the stomach and also open the bowels. A daily 
enema of tepid water continued for months will mostly suffice to alle- 
viate the troublesome symptom. Cod-liver oil, while being adminis- 
tered on account of the general indications, has also a beneficial local 
effect. Pure cow's milk is more contraindicated in this condition than 
in almost any other. Artificial food should contain a copious addition 
of salt and sugar, and oatmeal rather than barley. Gentle massage 
of the abdomen, and strychnine, one-two-hundredth of a grain, two 
or three times a day, improve the muscular strength. The syrup 
of the iodide of iron, in three daily doses of a few drops, and the 
regular administration of beef preparations, will improve constipation 
with the other symptoms, particularly when this treatment is com- 



SCROFULA 135 

menced at an early period. For it is at an early period, generally 
in the second or third month, that this rhachitic constipation makes 
its first appearance. It is one of the first symptoms of protracted 
rhachitis, and is diagnosticated from what I have described as con- 
genital constipation — which depends on the abnormal length of the 
sigmoid flexure — by the fact that the latter begins at birth. 

3. Scrofulosis {Scrofula). 

The discrimination between scrofula and tuberculosis is attended 
by no difficulty for those who claim the bacillus of Koch as the 
pathognomonic essence of the latter. For all others — and so it was 
before the period of the bacillus — the distinction may not be quite 
so easy ; at all events, the boundary lines between scrofula and tuber- 
culosis are not always quite marked. But it is certain that the bacillus 
need not be present in the former so long as it remains uncompli- 
cated. To diagnosticate " tuberculosis" when the lymph-bodies of 
the neck swell from below upward, and " scrofulosis" when from 
above downward, is a wanton postulation, for the mucous membranes 
of the nose and throat are as pervious to bacilli as that of the bronchi. 
The skin, mucous membranes, and lymph-ducts of the very young 
are very pervious, and access to and through them quite easy both 
to bacilli and to cocci. It is particularly the lymph-apparatus that 
is affected by scrofula. Even in the adult the lymph-bodies, with 
their copious cell-formation, retain an embryonal character, the lymph- 
vessels are numerous and large, and the lymph-current very energetic. 
A fistula of the thoracic duct in a young dog furnished lymph that 
equalled one-tenth or one-sixth part of its body weight, in a grown-up 
dog one-twelfth or one-sixteenth part. 

We speak of scrofula in persons who exhibit a great tendency, 
with no apparent, or upon the slightest, provocation, to subacute or 
chronic inflammation of most tissues, mainly the cutis and mucous 
membranes, sensory organs, glands, bones, and joints. It is character- 
istic of scrofula, in its incipiency, to be wide-spread ; of tuberculosis, 
however, in the vast majority of cases, to be localized. One or more 
localities in which scrofulosis is noticed may become the seat of 
tuberculosis, for bacilli will find a resting-place in softened tissue 
with slow circulation. These inflammations are persistent and liable 
to return ; they run their course with both rapid formation and 
disintegration of the cells, equally in the " erethic" and " torpid" 
forms. Of these, the former is recognized by a frail and thin form, 
delicate features, great intellect, blue sclerotic, and large pupils ; the 
latter, by a coarse and expressionless face, cedematous lips and nose, 



1 36 DISEASES OF THE BLOOD AND CONSTITUTION 

congested eyes, large abdomen, swollen glands, and frequent cutane- 
ous eruptions. 

It is the commendation of modern therapeutics to be mostly pre- 
ventive. So is the treatment of scrofula. Many cases of the disorder 
would not appear if our modes of thinking and feeling, our habits 
and laws, were not the immediate results of individual egotism. 
So long as the welfare of the commonwealth, both present and future, 
does not supersede, in the convictions of the many, the dictates of 
selfishness, there will be no restriction of the marriages of the scrofu- 
lous, syphilitic, and tuberculous, and the propagation and proliferation 
of their dangerous ailments. If mankind of the future means to be 
healthy and happy, there must be found some mode of preventing 
hereditary influences from having full sway. We are not Spartans, 
who kill the unhealthy newly-born, but we are to develop into men 
who pity those laden by their parents with the eternal curse of illness, 
and citizens who feel responsible for the physical and intellectual 
welfare of the community. In the United States scrofula has been 
on the increase at a rapid pace since the immigration of the most 
abject specimens of the most abject peoples of the Old World has 
been allowed to swell our numbers by the hundreds of thousands for 
each of the last two dozen years. 

An important preventive measure is the suppression of the attacks 
of acute diseases in children, mainly the eruptive fevers. It is urgent 
always to emphasize the necessity of medical (hygienic and pharma- 
ceutical) treatment of most cases of sickness. Measles and scarla- 
tina are particularly liable to interfere with the subsequent normal 
development, — the former through its influence on the respiratory, 
the latter through its effect on the digestive and lymphatic systems, 
and also on the bones. The modifications of a severe form into a 
milder form and the early restitution of the physical functions to a 
normal standard are gains for life. 

Scrofula being frequently the direct effect of digestive disorders, 
resulting either from improper food or nutriment improperly given 
or insufficiently digested, the greatest care is to be bestowed on both 
food and the digestive organs. This is of more than the average 
importance in regard to the offspring of tuberculous parents. No 
tuberculous mother should nurse her own infant. The selection of 
the wet-nurse should be the most painstaking, and the period and 
mode of weaning must be supervised with the utmost care. After- 
wards amylaceous food, particularly potatoes, should be avoided or 
given in small quantities only. Good milk (boiled), cereals, and meat, 
with the addition of fruit, ought to be the principal food of children 



SCROFULA. TREATMENT 1 37 

up to their tenth or twelfth year. Stimulants must not be given 
except on proper and exceptional indications ; thus tea, coffee, alco- 
hol, stimulating beverages of any kind, are forbidden articles of diet. 
Cocoa must take the place of chocolate. The best beverage is water. 
It supplies every want, and when taken in sufficient quantities is the 
best stimulant of tissue metamorphosis. In the very rare cases in 
which a sensitive stomach does not bear it well a carbonated or (and) 
slightly alkaline water will take its place. 

Among the additional foods, cod-liver oil ranks high. Most chil- 
dren take it readily after a short time, and are anxious to have it. 
Thus there was no necessity for peptonizing, emulsionizing, or 
" hydroleinizing" from the point of view of the children or of 
practice. Of the reprehensibility of filling the child's digestive 
organs with unlimited lime I have spoken in another place. The 
oil can be taken through successive years. Its administration ought 
to be interrupted during warm days and during the summer. Still, 
there are those who bear it well all the time. Fat children do better 
without it. In disorders of the stomach, and while the appetite is 
bad, -also during a feverish disease of any kind, also during a diar- 
rhcea, it must not be given (p. 8). 

Preparations of malt may be administered to advantage in small 
quantities several times daily. It is self-understood that the multitude 
of malt preparations containing medicines will be left by the intelli- 
gent practitioner on the shelves of the corner pharmacy. 

Tea of walnut leaves was a universal remedy in scrofulous affec- 
tions when tastes were simpler, medicines less in number, and less 
money was invested in expensive articles. Among the poor and in 
country districts it will prove an admirable adjuvant. 

Among medicinal preparations those of iron and iodine have met 
with most praise. The indications for the administration of the 
former are those of anaemia. When this is marked, iron ought to 
be given, and continued for a long period, according to the prin- 
ciples and methods laid down in a previous chapter. Potassium and 
sodium iodides and the tincture of iodine have been used. In the 
" erethic" form of scrofula they may do harm, and ought to be 
avoided. The same warning holds good in reference to those chil- 
dren who suffer from frequent attacks of bronchitis, which may 
already be the precursor or accompaniment of pulmonary tuberculosis. 
A sensitive stomach will not bear iodides. They may be made more 
digestible by the addition of a bitter tonic, and particularly by a few 
drops of tincture of nux vomica, diluted, with each dose. When the 
iodide results in bringing on the disagreeable or dangerous symptoms 



138 DISEASES OF THE BLOOD AND CONSTITUTION 

of iodism, the addition of potassium chlorate to the iodide, in doses of 
from ten to twenty grains daily, according to age, will prove bene- 
ficial. The potassium (or sodium) iodide may be taken in five- or 
six-grain doses, daily, by a child of two years, fifteen grains at ten 
years, for a long period. The sodium is better tolerated, as a rule. 
The tincture must not be administered in more than one-drop doses, 
three times a day. The syrup of hydriodic acid is often tolerated 
better than the previous preparations (from two to four cubic centi- 
metres = one-half to one drachm daily) ; of iodipin, which contains 
ten per cent, of iodine, a teaspoonful may be given daily (= seven 
grains of potassium iodide). The syrup of the iodide of iron is a 
valuable preparation, to be given three times a day in doses varying 
from three to twenty drops. So is the saccharated iodide of iron in 
three daily doses of from two to five centigrammes (gr. y$ to %). 

The indications for the use of iodine in general are also valid 
for that of the mineral springs containing that element, such as St. 
Catherine or Kreuznach. Fat children and those with cedematous 
swellings, glandular infiltrations, or the exudations resulting from 
scrofulous inflammations are mostly benefited by them. 

Of phosphorus, as a tissue-builder in subacute and chronic in- 
flammations of the bones, I have spoken in another connection (p. 
130). Its property as a stimulant of growth in general I have 
often verified in many morbid conditions. Scrofulous tissues, with 
their rapid decay and new formation, exhibit indeed the type of sub- 
acute inflammation, with the peculiar characteristic of rapid cell- 
proliferation, which perishes speedily because it is not sustained by 
a healthy connective tissue. The latter is formed by the internal 
administration of minute doses of phosphorus, such as I recommended 
for the above indications. Thus I refer to the remarks (made pre- 
viously on the subject) on the doses in which the drug is to be given, 
the period during which it is to be continued, and the impossibility 
of substituting for it any of its salts. Those who do not pin their 
faith on the treatment of any disease on any single remedy, but 
combine remedial measures with the proper regard to hygiene, will 
not be mistaken in their expectations of the effects of phosphorus in 
the treatment of scrofulous disorder. I have used arsenic for the 
same purposes and on the strength of the same indications, but 
it has appeared to me to offer less advantages in these conditions. 

A very active treatment can and should be applied to the lymph- 
bodies. Their tumefaction may be prevented in most cases. They 
swell under the influence of an irritation in the neighborhood. An 
intestinal catarrh will congest the neighboring mesenteric lymph- 



SCROFULA. LYMPH-BODIES 139 

bodies ; within a few days they become enlarged and hypersemic. 
When the local catarrh continues the hypersemia will result in hyper- 
plasia, and no long period is required to so change the tissue as to 
render the induration unabsorbable. If the diarrhoea " of the second 
summer," or of " teething," had not been permitted to go unchecked, 
these " scrofulous" glands would never have existed and therefore 
never interfered with lymph circulation and nutrition. Or the caries 
of a tooth, or a nasal catarrh, or a facial eczema, or one of the scalp 
is allowed to continue and develop into a chronic condition, and the 
secondary swelling of the glands round the throat and neck is the 
inevitable result. Principiis obsta. The greatest and gravest con- 
sequences might easily be prevented by attending to their trifling 
causes. Keep the mucous membranes healthy and the neighboring 
lymph-bodies will not be infected. 

When the lymph-bodies have had time to undergo induration, 
an attempt should be made at reducing them, though they be ever 
so hard or large. The frequent inunction of potassium iodide oint- 
ment made with lanolin will often carry the point; so will that of 
green soap. Which preparations ought to be used, and to what ex- 
tent the remedy, to what the massage of the parts alone is effective, 
are left to the decision of the practitioner. At the same time the 
syrup of the iodide of iron may be administered internally. 

When these measures have proved inefficient after a reasonable 
time, the indurated lymph-bodies should be removed. The operation 
is not always easy, but recovery is almost certain, and the protection 
afforded by it more than pays for every exertion on the part of the 
medical man and the temporary annoyance on that of the patient. 
When an abscess forms in the centre of a lymph-body, it should 
be enucleated. If it rupture, all the remaining parts of the lymph- 
body should be scraped out, disinfected, and made to heal. Sinuses 
should be laid open and the surface scraped off and treated with 
iodoform in oil or in glycerin (1 to 8 or 12) once every few days. A 
mild solution of dioxide may also be used a few times, or powdered 
zinc hyperoxide, or the same in an emulsion of ten per cent. 

Diseased bones should be treated on similar principles. Unless 
a scrofulous osteitis be superficial and within easy reach, the diseased 
parts ought to be removed with the least possible delay. The num- 
ber of cases recovering, though after a long time, and sometimes 
with shattered general health, without an operation, affords no excuse 
for those which have been permitted to develop into caries, or necrosis, 
or pyaemia, or leucocythsemia, or tuberculosis. 

Scrofulous conjunctivitis, keratitis, otitis, eczema, and arthritis 



140 



DISEASES OF THE BLOOD AND CONSTITUTION 



should be treated internally and to combat the morbid disposition, 
besides the procedures and appliances taught in subsequent chapters. 

That the scrofulous condition requires good air and ventilation 
may be mentioned, though it hardly appears necessary to do so. The 
children ought to be kept in the open air constantly. For that purpose 
the winters should be passed, if circumstances permit, in warmer 
climates. From that point of view the summer sea-sanitaria of our 
large cities and the similar institutions of the civilized countries of 
Europe have rendered valuable services. 

The skin of a scrofulous child must be kept scrupulously clean. 
But water must do more than merely that : the child must get used 
to cold water, and thereby accustomed to changes of temperatures. 
At the same time its nervous system will be strengthened and its 
cutaneous and cardiac circulation stimulated. The principles laid 
down in connection with the bathing of the very young hold good 
here, and I refer to my remarks on the subject. Salt water is prefer- 
able to plain water, and sea-bathing to either. Only in the cases of 
those who suffer greatly from eczema and other scrofulous eruptions, 
water must be avoided as long as the surface is not relieved. Indeed, 
no irritation of the surface is tolerated. Thus a scrofulous skin ought 
to be spared adhesive plasters or vesicatories, though the indications 
for their use be ever so tempting. 

Incidental diseases of scrofulous children require more than the 
usual care. The perishable character of all their tissues renders an 
average febrile or inflammatory disease uncommonly dangerous. Un- 
expected deaths are frequently met with in such cases. In them the 
avoidance of strong purgatives or depletions is the first command- 
ment; in them early feeding and sufficient general stimulation are 
among the principal indications ; in them cardiac tonics, given timely 
and plentifully, will save many a life that would otherwise succumb. 

4. Lymphatism. 

A number of infants and children exhibit a peculiar pallor, coupled 
with adiposity and rhachitical symptoms. I have alluded to this 
form of rhachitis repeatedly during many years. These patients, 
always pale and flabby, show a singular general debility. The laryn- 
gismus found in such children, with or without sudden death, like 
the other symptoms, glandular swellings, etc., I mostly attributed to 
this form of rhachitis; probably correctly, at least in many or most 
instances. Maybe others should be explained differently. 

The so-called " lymphatic state" is a condition of pallor, adiposity, 
hyperemia, but otherwise normal structure of most organs, rather 



LYMPHATISM. LIPOMATOSIS 141 

large (sometimes very large) spleen, thymus, and also thyroid, rha- 
chitic epiphysitis, swelling (in different degrees) of the lymph-bodies 
of the neck, axillae, mesentery, of the tonsils and the follicles of 
the nasopharynx, and of the tongue. This condition is also com- 
plicated with hypoplasia of the (heart and) arteries (Virchow, dif- 
ferent from actual rhachitis, in which the arteries are rather large), 
which explains many a case of chlorosis and also of haemophilia, 
sometimes with infantilism of the sexual organs, hairless pubes, and 
lymphocytosis. Sudden deaths seem frequently to be due to this 
condition, or rather to the excessive weakness of the heart connected 
with it (Paltauf, Escherich, J. Ewing). The heart being weak, 
chloroform inhalation, otherwise preferable to ether in children, be- 
comes dangerous. Escherich tried the effect of calf-thymus feeding 
in this complex ailment, with negative result. Besides general anti- 
rhachitic treatment, I should feel like relying mainly on phosphorus 
and cereal and animal foods. Lymphatic children in whom the above 
symptoms may be feared can be protected by moderate doses of 
bromides or a few daily doses of ten or fifteen drops of tincture of 
musk. Iron preparations should be used carefully (ferratin, the 
albuminate, or the peptonate). 

In some cases of general lipomatosis of children of both sexes 
I was struck with the smallness of their radial and carotid arteries 
and their feeble heart-beats. The percussion of the heart yields 
very questionable results, on account of the thickness of the chest- 
walls. Still, these were never so thick as to prevent the percussion 
of the thymus behind the manubrium sterni. In several instances it 
was found to be large, even in patients of ten and twelve years. In 
every one of its varieties, lipomatosis, being general, is a serious 
danger in any intervening disease. All the organs, mainly the heart, 
being liable to be incompetent, stimulants and roborants should be 
given through the whole course of feverish diseases intervening in 
excessively adipose children. Intertrigo is very common and obsti- 
nate. Adiposity of the nurslings is not a pleasant symptom, and the 
increase of their -weight, generally claimed as a proof of good health 
and of thriving, is rather deceptive. Unless it be excessive, however, 
it will disappear about and after the end of the first year when mus- 
cles develop more effectually. As a rule, their blood is defective in 
erythrocytes and in haemoglobin. The fat babies of fat mothers should 
be weaned, or cereals and animal food should be added to breast-milk ; 
perhaps iodide of iron given. 

The diet should be principally albuminous, with a fair amount of 
fat, very little vegetable carbohydrates, and little water. General 



142 DISEASES OF THE BLOOD AND CONSTITUTION 

massage, exercise, for a while sodium sulphate every morning, and 
iodide of iron are helpful. Thyroid may safely be given, with some 
caution and combined with a cardiac stimulant (strychnine), to ad- 
vantage. In hydremic anaemia also, with or without a slight enlarge- 
ment of the thyroid, and in marked simple anaemias, with or without 
enlarged spleen, besides lipomatosis, thyroid (as recommended by N. 
Koplik, Arch, of Fed., July, 1897) should be tried in combination 
with the treatment detailed above. 

5. Diseases of the Ductless Glands. 

Their " internal secretion" is required in the organic economy 
either as an additional element or for the purpose of destroying the 
toxic results of metabolism. 

Pseudoplasms of the thyroid gland are not often observed in in- 
fancy and childhood ; still, even carcinoma and tuberculosis have been 
noticed. Syphilitic gummata have been found, and would, if diag- 
nosticated, demand specific treatment. A dermoid tumor was re- 
moved from an infant two hours old, who recovered (London Lancet, 
May 22, 1897). Atrophy with myxoedema has been reported in a girl 
of twelve years ; its treatment consisted in the administration of 
thyroid gland. Inflammation has been known to follow trauma and 
infectious or common catarrh of the nose and naso-pharynx. The 
treatment should consist of local applications of ice, hydrotherapeutic 
measures in general, saline purgatives, irrigations (both cleansing 
and antiseptic) of the nares and pharynx, and perhaps iodine both 
internally and externally, when absorption is slow. Suppuration re- 
quires early incision. Goitre — struma — is mostly met with in the 
lateral lobes, and therefore is not liable to annoy respiration until it 
becomes very large ; should it do so, it compresses, particularly when 
behind the sternum, the trachea, vessels, and nerves. The usual 
forms found in the adult (lymphatic, cystic, even colloid and fibrous) 
are observed. When congenital, it is apt to be absorbed unless it be 
syphilitic and in need of mercurial combined with iodine treatment ; 
the age of puberty also predisposes to spontaneous decrease. Most 
cases presented were in children from seven to ten years old. An 
occasional pulsation is not, of itself, pathognomonic of Graves's dis- 
ease. An epidemic — infectious and contagious — form of goitre has 
been observed in schools, but was only a temporary ailment. Tincture 
of iodine, strong or modified, may be applied once every few days, 
or potassium iodide in glycerin (1 to 2 or 8), or a potassium iodide 
ointment with lanolin ( 1 to 4 or 10) may be rubbed in several times 
daily. Potassium iodide may be given in doses of from five to fifteen 



DUCTLESS GLANDS. CRETINISM 143 

grains daily. Iodine, indeed, appears to have, in bacteric and in thy- 
roid poisoning, antitoxic properties, the toxalbumin of the thyroid 
having a great affinity to iodine. With potassium iodide injections 
into the tissue of the enlarged gland I have had no experience. In 
simple hypertrophic goitre and diffuse colloid degeneration injections 
(as many as fifteen) have been made every other day or every third 
day, with effect beginning to show itself after the sixth or seventh, of 
iodoform one, ether and olive oil each seven parts, the dose to be one 
or two cubic centimetres (min. xv or xxx). The cystic form requires 
puncture with injection of Lugol's solution; if the secondary swelling 
be too large and annoying, ice should be applied. Or the cyst or 
cysts may be incised and tamponed with aseptic gauze. If extirpa- 
tion be preferred, it must not be total, because of the consecutive 
occurrence of cachexia strumipriva, tetany, and myxcedema. 

Extirpation has the same effect as that observed in cases of ab- 
sence or of degeneration of the thyroid gland. This degenera- 
tion may lead to atrophy or to an apparent hypertrophy; that is 
why thickness of the thyroid should not be taken for normal tissue. 
Myxedema (mainly characterized by that condition of the thyroid, 
by the peculiar myxomatous structure of the skin and subcutaneous 
tissue, and by mental failure) is seen in the young as well as in 
the adult. In the young it is mostly complicated with cretinism 
or semi-cretinism ; in many cases the absence or degeneration of the 
thyroid may be its only cause, in many others it exhibits at the same 
time changes in the skeleton, prominent among which is the shorten- 
ing of the cranial base produced by the premature ossification of the 
occipito-sphenoidal synchrondrosis. Thus, with the exception of the 
latter, the cretinism of the foetus and of the infant and the myxoedema 
of the young and of the adult are results of the same anomaly. 

This cretinism is by no means so rare among us as it has been 
reputed to be even by the best observers. The patients, with their 
thick, short neck, clumsy looking head, retracted root of nose, wide- 
apart eyeballs, thick lips and tongue outside the teeth, large abdo- 
men, dwarfed stature, and indolence, seldom appear in practice. 
They are occasionally found in the retreats of the tenement-houses, 
where the general practitioner may happen to see them, though he be 
not consulted about them ; only of late they turn up in the dispen- 
saries. 

In the therapeutics of cretinism in most of its forms the thyroid 
gland, in its various preparations, has worked a beneficial revolution, 
as it also has in that of myxcedema. This addition to our facilities 
for overcoming a formerly incurable ailment, at least to a certain 



144 



DISEASES OF THE BLOOD AND CONSTITUTION 



extent (for no perfect recovery is known as yet), is, as Meltzer has 
so well shown {New York Med. Monatsschrift, May, 1895), emi- 
nently due to biological experiment and to it only. There are but 
few cases that resist its efficacy. The doses, however, must be small, 
particularly in the beginning ; from one-third of a grain to one grain of 
Parke, Davis & Co.'s powdered thyroid three times a day, the small 
dose first, the larger one afterwards, are all that ought to be given an 
infant or child, according to age. The treatment must be continued a 
long time. It cannot be expected to act so well as in the myxcedema 
of the adult, because the cretinism or semi-cretinism of the child is the 
result of an arrest of development at a very early period of intra- 
uterine life. It follows that the treatment ought to begin as early as 
the diagnosis can be made. Besides the powder of Parke, Davis & 
Co., I know only Armour's preparation and the tablets of Burroughs 
and Wellcome. They are not of equal strength, and in every case 
ought to be commenced in small doses ; for sometimes even appar- 
ently small doses produce general and cardiac irritation, palpitation, 
tremor, debility, and diarrhoea. On the other hand, rather large doses 
may be required. In a cretin six years old, in hospital treatment, 
I was obliged to increase the doses from one and one-half grains 
(0.1) daily to thirty-six (!) grains (2.5), which were taken a 
number of days before the pulse became more frequent, mild per- 
spiration and restlessness showed themselves, and the temperature 
rose slightly. The general improvement was rapid. Other effects of 
the thyroid medication are obtainable in the child as in the adult. 
Myxcedema, the near relative of cretinism, shows its main symptoms 
in the subcutaneous tissue and in the skin, which are thickened and 
hard, and in the nervous system. I have seen good results of the 
thyroid treatment in cases of excessive adiposity, — one boy of eleven 
years, weighing one hundred and fifty pounds, was reduced to one 
hundred and twenty in four months under the use of small doses, — 
in scleroderma, and in a case of psoriasis. Fortunately, such cases 
are rare. Moreover, the thyroid treatment has proved very efficient in 
instances of stunted growth in the child and adolescent, with or 
without stunted intelligence. The effect was several times quite 
astonishing, both the length of the body and its general condition 
being rapidly improved. 

The attempts at isolating the active principle, either organic or 
probably chemical, have proved successful in a good many cases that 
indicated thyroid medication. The dose of iodothyrin is like that of 
the thyroid substance. Its disagreeable effects may be modified by 
the use of arsenic. Burroughs-Wellcome's thyroidin, sold in tablets 



EXOPHTHALMIC GOITRE 145 

of 0.25 (four grains), may be given in similar doses. Aiodin, another 
thyroid preparation, is recommended in the same way. It is claimed 
to contain 0.4 per cent, of iodine, and is therefore warmly recom- 
mended in the treatment of scrofulous lymph-bodies. The thyro- 
antitoxin of Fraenkel is recommended in doses (to an adult) of one 
centigramme (one-sixth grain), five or six of which may be given 
daily. 

Not infrequently I have combined arsenic or phosphorus with 
the thyroid, some of the cases of cretinism showing characteristic 
symptoms of rickets. Indeed, the condition of the base of the skull 
appears to be one of the manifestations of localized rhachitis which 
has completed its entire course before birth. 

The lasting effect of thyroid administration is rather jeopardized 
by the necessity of persisting in the treatment in order to escape 
relapses. Horsley's attempts at transplanting glandular substance 
will have to be repeated until they are successful and place the effect 
of the miraculous therapy beyond any risk. Such risks exist. The 
effect, sometimes of small doses, may be distressing, — prurigo, per- 
spiration, tachycardia, delirium, even tonic spasms, and undesirable 
loss of weight ; glycosuria rarely. In all these symptoms the effects 
of the treatment resemble very much those of exophthalmic goitre 
(Graves's or Basedow's disease), in which the thyroid is enlarged 
and in all probability the seat of abnormal functions. 

Exophthalmic goitre is not a frequent disease in childhood. Of 
twelve cases reported in literature until 1879, f° ur were mine (New 
Y-ork Medical Record, July 5, 1879) 5 they occurred in children of 
from nine to thirteen years. Nor are the symptoms so grave as they 
are liable to be in the adult ; in many, not all of the three alterations 
(exophthalmos, goitre, and tachycardia) are found at the same time. 
In the treatment proper regard must be paid to diet and hygiene. No 
excitement, fear, work, stimulants. Prolonged or but partial rest in 
bed at home or in a hospital. Baths of moderate temperature. Ice 
to the heart and (or) to the goitre for days, or hours, in succession. 
Application once or twice daily of a mild galvanic current (negative 
pole, from one to three milliamperes) from five to ten minutes over 
the sympathetic nerve, between the horn of the hyoid bone and the 
sterno-cleido-mastoid muscle. Digitalis and strophantus act badly, 
and are apt to increase tachycardia; potassium iodide acts more 
favorably. Gowers recommends belladonna in rising doses. My most 
successful medicinal treatment has been with arsenous acid, from two 
to six milligrammes (one-thirtieth to one-tenth grain), atropine from 
one-third of a milligramme to one milligramme (one-one-hundred- 

10 



146 DISEASES OF THE BLOOD AND CONSTITUTION 

and-eightieth to one-sixtieth grain), and fluid extract of ergot a 
gramme (fifteen grains) or more daily. I lately had a child's case 
under observation for some time, and was favorably impressed with 
the effect of thyroid in that case. Possibly it acts better in children, 
in whom the course of the disease is mostly milder; for, so far as 
adults are concerned, experience does not seem to be favorable. It is 
quite possible that Graves's disease will be much more influenced by 
the administration of thymus gland. Reinbach found fresh thymus to 
act in cases of goitre in which thyroid treatment had proved ineffec- 
tive. The direct dependence of Graves's disease on the condition 
of the thyroid glands appears to be proven by the result of operations 
(partial removal), which, according to Oppenheimer, cured eighteen 
and improved twenty-six out of sixty-six cases. Nine died within 
a day after the operation. Of late the results of operations are 
greatly better; Kummell, for instance, operated on fourteen severe 
cases of exophthalmic goitre with partial removal of the thyroid gland ; 
twelve were permanently cured. The report was made from two to 
seven years after the operation. The remaining part of the gland 
showed a tendency to shrink; in one case only it grew a little larger. 
The other two cases were cured, with the exception of the exoph- 
thalmos, which persisted at first, but gradually diminished in size 
(Berl. Klinik, June, 1897). Doyen reported two equally successful 
cases (Sem. Med., 1897, p. 280). Sorgo collated 174 cases of stru- 
mectomy performed on adults who had Graves's disease ; recovery 
took place in 48, considerable improvement in 27, moderate improve- 
ment in 62, no improvement in 11, death in 24 soon after the opera- 
tion. Mikulicz arrives at the following conclusions : after a partial 
removal of the thyroid the first symptoms to disappear are the nervous 
and psychic, tachycardia takes more time, exophthalmos disappears 
late or not at all. Resection of the sympathetic about the neck has 
lately been recommended (Jonnesco), total and bilateral, inclusive of 
the inferior cervical ganglion. 

Favorable results of the thyroid treatment have been mentioned 
in regard to dwarf growth and psoriasis. Further mention should be 
made of prurigo, of acromegaly, and of hyperplastic otitis interna in 
young obese persons. The absence of the thyroid function certainly 
retards the growth of bones, while it seems to leave intact the large 
abdominal viscera. It has sometimes improved tetany and certainly 
has a very favorable effect in simple hyperplastic goitre, in which the 
normal structure of the gland has been destroyed. 

Diseases of the thymus gland are not yet very amenable to treat- 
ment. Inflammations, abscesses, syphilis, tuberculosis, sarcoma, 



THYMUS. ACROMEGALY 147 

lymphadenoma, carcinoma, hemorrhage, and sclerosis have been ob- 
served. Its physiological dignity in the fcetus and young infant is 
certainly great. Nearly half a century ago Friedleben proved that it 
is indispensable in the foetal and infant economy. It is largest (nor- 
mally) from the third to the twentieth month ; about the ninth month 
it was found, in unusual instances, from 1.5 to two centimetres in 
thickness. As the distance between the manubrium sterni and the 
vertebral column is but two centimetres about the eighth month of 
life, the slightest increase of an enlarged thymus through disturbed 
circulation, by crying or otherwise, may prove suddenly fatal ; for 
besides the thymus, the oesophagus, the trachea, the blood-vessels, and 
the sympathetic and pneumogastric nerves are located in that narrow 
space. Bending the head backward during tracheotomy proved fatal. 
Swelling of the thymus in a cold bath may be dangerous. 

Another danger is the irritation of the recurrent nerve by the con- 
stant up-and-down movement of the thymus gland. In such a case 
death may occur. It is cardiac, for at the autopsies there was no 
injection of the pia mater and no suggillations in the lungs. 

Koenig (1897, after Rehn, 1896) extirpated a part of the thymus 
of an infant of nine weeks that suffered from intense dyspnoea. The 
remaining part he attached to the manubrium sterni and the tendons 
of the sterno-cleido-mastoid muscles ; recovery was complete in four 
weeks. Thus, local pressure or irritation by the greatly enlarged 
gland may prove fatal, though most cases of sudden death in laryn- 
gismus stridulus must be explained otherwise. A recent case of 
death from large thymus occurred nine hours after birth (Schleif). 

Like the thyroid, the thymus was found enlarged in many, accord- 
ing to Erb in all, cases of acromegaly. 

Acromegaly — enlargement of all the tissues (except the skin) of 
hands and feet, of both maxillae, with alveolar processes, so that the 
base of the face is below (while it is above in Paget's osteitis defor- 
mans, and the shape of the face is round in myxoedema), of ears, of 
tongue, and thorax, now and then hereditary, multiple in families, 
occasionally with disorders of the pancreas, in the adult with early 
arteriosclerosis, with deformity of the chest and enlarged viscera, 
seldom with glycosuria — was attributed by Marie to hyperfunction of 
the hypophysis (pituitary gland), which is in part a secreting organ 
without a duct, so that the lymph-vessels carry off the secretion. 
Marie, therefore, looks upon acromegaly (and many cases of gigantic 
growth: several professional giants were found to be acromegalic) 
as a nutritive disorder connected with an anomalous hypophysis, as 
myxoedema is with the thyroid gland. Possibly, as the thymus ap- 



148 DISEASES OF THE BLOOD AND CONSTITUTION 

pears to be affected, acromegaly is the result of the complex anomalies 
of several organs. The treatment with hypophysis gave no conclusive 
results; nor that with thymus. The latter was also employed by 
Macalister in pseudo-hypertrophy, and by Mikulicz in goitre and 
Graves's disease; in the latter it has also been used by Owen, Cun- 
ningham, Edes, and Solis Cohen. N. Mackenzie reported twenty 
cases treated with thymus (Amer. Joum. Med. Sci., February, 1897). 
One died, six showed no improvement, thirteen showed some improve- 
ment, which, however, was not considered marked or conclusive. 

Hypertrophic osteo-arthropathy was described by Bamberger and 
in 1890 by Marie as clubbing of the last phalanges and thickening 
of the nails of fingers and toes, enlargement of all the phalanges, 
and later of the bones of the forearms and legs and joints ; not of the 
face and skull. It is connected with or dependent on suppurative 
lung diseases, empyema, abscess of the lung, bronchiectasis, and sar- 
coma of the lungs. Venous obstruction may now and then be a 
causal factor, but the influence of toxins formed in cavities is more 
probable. It is by no means so rare in children as it is reputed to be. 
In a small hospital service I saw two cases in one year. They are apt 
to improve with the improvement of the local trouble. 

Addison's Disease. — The " suprarenal melasma" depends on anom- 
alies (tuberculosis, carcinoma, induration, hemorrhage) of the adre- 
nals. According to Otto Ramsay {Johns Hopkins Hosp. Bull., vol. 
x., 1899, p. 24), of thirty-five cases of carcinoma whose ages were 
known five were between one and twenty years, of twenty-six cases 
of sarcoma whose ages were known eight were between six months 
and ten years old. Such tumors were more frequent in the male, and 
attended by pain and emaciation, and exceptionally only with changes 
in the skin. Removal was successful in two cases. In some cases the 
semilunar ganglia have been charged with being its cause. Great 
muscular weakness, debility of the heart, frequent and small pulse, 
irritability, later apathy, cephalalgia, cardialgia, decrease of red blood- 
cells, and exhaustion (together with the characteristic discoloration of 
the skin) are the symptoms common to a number of constitutional 
ailments leading to a slow death. The treatment is, therefore, to a great 
extent, that of the anaemias, and requires iron, arsenic, strychnine, 
and measures directed against incidental symptoms, such as diarrhoea. 
Adrenals have been given in powder or in glycerin extract, or raw or 
cooked. Tabloids are prepared by different manufacturers, in which, 
as a rule, one grain corresponds with fifteen grains of the dried ex- 
tract. They mostly weigh five grains ; not more than one daily would 
be a dose for a child. Locally the fresh watery solution (suspension) 



ADDISON'S DISEASE. ORGANOTHERAPY. SPLEEN 149 

of the powdered extract has been used extensively on account of its 
blood-vessel-constricting power in conjunctivitis, rhinitis (hay fever), 
pharyngitis, and as a haemostatic, now and then in combination with 
cocaine. Parke & Davis's " adrenalin" is a solution of one in one 
thousand, and is to be used in drop doses ( 1 to 4) several times a day, 
ten or more in the adult. According to T. B. Aldrich (Amer. Journ. 
Phys., vol. vii. p. 359), adrenalin is identical with the copper-sul- 
phate-reducing body, the blood-pressure-raising substance, as found 
in the gland, and is therefore the active principle of the same, and not 
a changed or modified form as I. J. Abel contends (Johns Hopkins 
Hosp. Bull., 1901, vol. vii.). Epinephrin appears to be a changed 
form of adrenalin. It does not reduce Fehling. The equivalent of 
two glands was administered by Osier, with varying results; he has 
a case (adult) that gained fifteen pounds in six weeks and felt 
stronger (" Princ. and Pract. of Med.," 2d ed., 1895, p. 749). 

Most valuable general information on organotherapy we owe 
to Hun and (Amer. Journ. of Med. Sc, July, 1897) to Kinnicutt, 
who gave the results of vast experience and large numbers. Accord- 
ing to him, in accordance with other observations, the myxcedema of 
cretinism is readily removed by thyroid treatment. The earlier it 
is commenced in the young the greater is its influence on growth 
and mental development. In the idiot, with a lymphatic rather than 
a myxcedematous condition, improvement is also obtained. Hyper- 
plastic goitre (not the cystic) is greatly improved if not cured. Exoph- 
thalmic goitre was not improved ; on the contrary, many patients felt 
worse. Obesity is influenced rapidly, losses of from two to eleven 
pounds having been observed ; these losses will continue for some 
time only. Psoriasis is influenced to a certain extent only; the thy- 
roid treatment seems to have no better effects than others. Other 
skin diseases were not particularly benefited. Of forty-eight cases 
of Addison's disease treated by suprarenal extract, six were cured, 
twenty-two improved, eighteen not improved, and two aggravated. 
Thymus extract appears to be useless in exophthalmic, beneficial in 
hypoplastic goitre. Of thirty cases, there was improvement in twenty, 
a cure in two. Pituitary preparations were used in thirteen cases of 
acromegaly. Varying degrees of improvement were noticed in seven, 
none in five, and one became worse. In one the affected extremities 
decreased, in two the pain in the head and limbs diminished.* 

Diseases of the spleen are rarely of a primary character; but 



* Thymus has been administered in adrenal disease, because the thymus 
gland was often found enlarged in it. 



15° 



DISEASES OF THE BLOOD AND CONSTITUTION 



most cases of psendoplasm are congenital, and not amenable to any 
medicinal treatment, except sarcoma, which cannot be cured, but may 
be favorably influenced by arsenic and by the toxin of the erysipelas 
coccus and the bacillus prodigiosus (Coley). It is not so rare as it is 
reputed to be. I am certain that I see a case annually. The majority 
of changes occurring in the spleen are connected with, or dependent 
on, constitutional ailments, and result mostly in enlargement of the 
organ. Malaria, leucocythaemia and pseudo-leucocythsemia (Hodg- 
kin's disease), and amyloid degeneration have their own indications. 
Rhachitis and syphilis are liable to produce induration depending 
on hyperplasia of the connective tissue. Tuberculosis of the spleen 
is a frequent complication; sometimes, in the very young, the spleen 
is the first place of deposit of acute tubercular infection. The de- 
posits are sometimes of microscopical size only. The differentia- 
tion between tubercular deposits (transparent in very acute cases 
only, otherwise slightly yellowish, sometimes caseous, of unequal 
size and irregular distribution) and the follicles of the spleen is not 
always easy. Heart disease may lead to embolism, infarctions, rup- 
tures, and abscesses (the latter forming also a part of general pyae- 
mia), typhoid fever to softening and enlargement. This condition 
expands the peritoneal covering and causes perisplenitis, though it be 
not always distinctly amenable to diagnosis. For, indeed, the younger 
the infant the less is percussion — being hampered by the frequency 
of tympanites — able to reveal the exact size of the spleen. Unless 
it can be felt below the margin of the ribs, it should not be assumed 
to be enlarged. There are even cases in which it can be so felt, and 
still there is no enlargement, for in some instances the spleen is found 
descended or floating (" ptosis"). 

Banti has described a condition in which the spleen is enlarged 
for years, the enlargement is then followed by ascites, and finally by 
cirrhosis of the liver, the reversed order of the symptoms observed in 
the latter condition. Haemoglobin was found to be reduced more than 
would be explained by the reduction of the red blood-cells. 

As primary splenomegaly, or splenic ancemia, a condition has 
been described which furnishes a large spleen, anaemia without leuco- 
cytosis ; sometimes hemorrhages, ascites, and enlarged lymph-bodies. 
For this condition, as also for malarial hypertrophy, for floating 
kidney, and for rupture, the spleen has been extirpated, with in- 
creasing successes. In leucocythaemia it has not been successful, 
maybe because the operation was performed too late. Possibly other 
organs assume the function of the spleen after its removal ; for 
Hodenpyl found a general (compensatory?) lymph-body hyperplasia 



HEMORRHAGIC DIATHESIS 151 

in a case of absence of the spleen. The same has been observed in 
some cases of splenectomy. 

The therapeutics of the constitutional disorders above alluded 
to has been discussed in previous papers. Quinine, ergot, and arsenic 
have been shown to be efficient in some and absolutely inert in others. 
The combination of quinine and ergot, with or without iodides, is 
probably among the most powerful remedies in chronic cases. Acute 
instances of swelling and inflammation require ice energetically ap- 
plied, purgatives, and large doses of ergot; the presence of pus 
demands incision and drainage. To ascertain that condition exploring 
punctures, carefully executed, can be made with safety. To what 
extent extirpation of the organ can be rendered serviceable in chronic 
cases remains for the future to demonstrate. Many of them that 
are dependent upon disorders of circulation or nutrition are more 
amenable to a preventive than to a curative treatment. 

6. Hemorrhagic Diathesis. 

Under this heading I propose to treat of purpura, the hemorrhagic 
disease of Werlhof, scurvy, peliosis rheumatica, and hcemophilia, be- 
cause of their similarity of symptoms and their — to a certain extent 
— uniform anatomical cause. Among them all, the first, with its 
wide-spread petechias and subcutaneous and cutaneous hemorrhages, 
is most frequently mentioned. It results from all causes interfering 
with general nutrition, and particularly with that of the blood-vessels. 
Among them are poverty, uninhabitable dwellings, chronic gastro- 
intestinal catarrh, overdoses of turpentine, dysentery, typhoid fever, 
diabetes, miliary tuberculosis, pneumonia, diphtheria, scarlatina, 
measles, grave anaemia, leucocythaemia, hepatic and renal diseases, 
and severe intestinal autointoxication. Relapses are very common. 
The complications with hemorrhages from the mucous membranes of 
the nose, stomach, and intestines, from the kidneys, into the brain and 
retina, and often with fever, are denominated Werlhof's disease. The 
diagnosis of " scurvy" requires bleeding from the gums, " peliosis" 
complications with " rheumatic" pain and swelling of the joints, but 
without an affection of the heart, and haemophilia the hereditary ten- 
dency to general or only local (kidneys, gums) bleeding of (mainly) 
the male transmitted through the female, on the bases (Virchow) of 
narrowness of the arteries and insufficient development of the thin 
blood-vessel walls. 

The alleged defective condition of the blood does not explain the 
hemorrhagic tendency. No blood, though ever so thin, penetrates a 
healthy blood-vessel wall. Hydraemia by itself does not produce 



152 DISEASES OF THE BLOOD AND CONSTITUTION 

bleeding without an impaired condition of the tissue of the blood- 
vessel; thus it is that the same degree of anaemia in women may 
result in metrorrhagia in one, in amenorrhea in another. Infants 
are peculiarly liable to bleed, because in them the blood-vessel tissue 
is still undeveloped ; the embryonic condition extends into early in- 
fant life, and frequently gives rise to hemorrhages into the brain, 
meninges, and other serous membranes. When morbid influences are 
added to this physiological predisposition, the result is easily compre- 
hended. 

These influences are unknown. Bacteriological explanations are 
not yet quite satisfactory, in spite of Babes and many others. Finkel- 
stein (Charite Ann., vol. xxi.) connects the hemorrhagic diathesis 
with the bacillus pyocyaneus, and found streptococci in the blood-vessel 
walls. It is possible that all these varieties of hemorrhagic diathesis, 
which have been subsumed by Wilhelm Koch under the common 
heading of " scurvy," are more or less acute infectious diseases. That 
suspicion appears particularly justified in regard to purpura ful- 
minans, a few cases of which have been observed in the very young 
(Henoch). 

The treatment is to a great extent preventive. The social condi- 
tion of a large part of the population is a main cause and ought to be 
improved. Thus the successful treatment depends largely on the 
prosperity of all, and is another proof of what ought to be considered 
a fact, that medical and social questions and aims are frequently iden- 
tical. Zymotic disorders and eruptive fevers should be treated with 
a view of sustaining the strength of the system and the vigor of cir- 
culation. The heart's action ought to be watched constantly, and 
cardiac tonics given before heart-failure sets in. The dietetic treat- 
ment of these diseases is at least as important as their medicinal man- 
agement. In this way hemorrhagic diathesis is kept off, as well as 
exhaustion. 

Medicines can accomplish a great deal, but ergot less than it is 
often credited with. In these conditions I have often met with its 
untoward influence on digestion, and but rarely with a favorable 
influence on the hemorrhagic deposits or processes. Perhaps hy- 
drastis does better, stypticin in one-tenth of a grain (0.006) doses 
frequently, adrenal substance a few grains daily, adrenalin (Parke & 
Davis) in drop doses, and gelatin subcutaneously in one- or two-per- 
cent, sterilized saline solution. Stronger solutions may be used 
locally on a bleeding surface or in the rectum. The styptic effect of 
calcium chloride, from five to ten grains (0.3 to 0.6) daily in all 
forms of hemorrhage, appears to be well established. It has been 



SCURVY 153 

administered to pregnant women in bleeding families. Iron does not 
appear to yield desirable results; among its preparations the tincture 
of the chloride is perhaps the best ; the tincture of the malate and the 
liquor of the albuminate are well tolerated. Digitalis has a favorable 
effect on the heart's action ; an infant of a year may take the equiva- 
lent of from one to four grains daily for some days, two grains daily 
afterwards. With it strychnine may be combined ; the same baby may 
take a fiftieth of a grain daily. As relapses are quite frequent, the 
invigoration of the blood-vessels is the main object in view. From 
one to three drops of Fowler's solution, largely diluted, may be given 
every day for a long time. Better still is phosphorus, the method of 
administration and the doses of which have been detailed in a former 
chapter. Lead and tannin have not satisfied me at all. Local hemor- 
rhages, when accessible, will require the application of ice, or com- 
pression of the bleeding vessel. The solution of antipyrin (5 to 20 
to 50 per cent.), with or without tannic acid, is a good styptic. The 
success of the preventive treatment of haemophilia will be rather 
doubtful so long as individuals are not controlled by the community 
in regard to the demands of public health. The daughters of haemo- 
philic families ought to be prevented from, and protected against, 
contracting marriages and having children. Phosphorus, adminis- 
tered in small doses and continued a long time, seems to diminish the 
tendency to bleeding. 

Infantile scurvy {Barlow's disease) has become very amenable 
to treatment, both in its early and in its advanced stages. Its main 
and characteristic symptoms are pain and immobility of the (mostly 
lower) extremities; swelling (mainly) of the diaphyses, which de- 
pends on subperiosteal hemorrhages; petechiae, and ecchymoses over 
any part of the skin, particularly of the eyelids ; spongy condition and 
purple color of the gums, no matter whether teeth have appeared or 
not (contrary to Barlow in Keating-Edwards's Cyclopaedia, vol. v., 
1899) 5 an d sometimes separation of an epiphysis. These symptoms 
are frequently complicated with the tumefied epiphyses and other 
marks of rhachitis. The prognosis is mostly good. The principal 
remedy is fruit- juice, that of from one to two oranges a day, or of 
a pineapple; it is the specific. Complications with rhachitis require, 
besides, the elixir of phosphorus. Sterilized milk, if the only nutri- 
ment, as in many instances it will be found to have been, should be 
banished. If no reliable sweet milk be accessible, it should be pas- 
teurized and combined with cereal (barley, oatmeal) decoctions, and 
meat-broths or some meat- juice should be administered as a regular 
food. Within a few days recovery will begin. 



154 DISEASES OF THE BLOOD AND CONSTITUTION 

7. Diabetes. 

Diabetes mellitus is by no means a common disease among infants 
and children, but it is not so rare as some will have it, — even acute 
diabetes running its full course within one or two weeks, mostly 
from trauma of the head, has been observed, — nor so frequent as 
those assert who have found glucose in the urine of infants whose 
food was supplied with an unusual quantity of sugar. Indeed, traces 
of sugar are often met with in the urine of nurslings. But this is not 
" diabetes." 

In the ten years before i860 there were thirty-one deaths from 
actual diabetes in Great Britain in children under fifteen years, an- 
nually. Since that time the occurrence of the disease in every period 
of life appears to have become more frequent. Hereditary (Blumen- 
bach) and family influences, such as neuropathies, epilepsy, insan- 
ity, syphilis, exert a great influence. Isenflamm reports seven diabetic 
children in one family ; Thomas three brothers ; Mosler a diabetic 
woman whose father, mother, two sisters, and son died of diabetes ; 
Naunyn five children in one family. Caron reports the cases of three 
children of the same mother, at the ages of three and a half and one 
and a half years, and of three months. I have seen two boys in one 
family, of five and three years, and other instances of multiplicity 
of the disease. Hydrocephalus, injuries to and tumors of the head, 
colds, atrophy of the pancreas, dysentery, morbus maculosus, measles, 
and scarlatina are referred to as causes. In most of the cases which 
have come under my own observation I could not elicit one. The 
highest percentage of sugar I have noticed in a child (boy of four 
years) was six and one-half. Heubner observed eight and one-half, 
with a daily quantity of five thousand grammes, or five quarts ; Leroux 
ten and one-half. But it is not so much the percentage as the total 
amount of glucose eliminated in a day that is of importance. The 
specific gravity of the urine is not always high ; I have seen it as low 
as 1007 and 1005. The prognosis is not so good as Redon and a 
few others appear to believe. Twenty-five years ago Kiilz reported 
six recoveries in one hundred and eleven, Wegeli, thirty-nine in one 
hundred and eight cases. I am afraid the diagnosis was obscured by 
the facility with which copper is reduced by creatinin, creatin, and 
other constituents of the urine.* Therefore, several (different) tests 

* Possibly, but not probably, as only five pure cases have been reported, 
a mistake could be made in regard to " pentosuria," which is no illness, it 
appears, and may occur in full health. In it there is a correct glucose reaction 
by Fehling and by Nylander, but not by fermentation (Salkowski). 



DIABETES 155 

should be employed when dry skin, emaciation in spite of ravenous 
appetite, polyuria with high specific gravity (up to 1044), a ^ so furun- 
culosis, are noticed. A new and reliable test was furnished by J. Ru- 
disch (Festschrift). The disease runs a more rapid course in infants 
and children than in adults, and terminates more readily in coma and 
death. I have seen recovery in but twenty cases. Therefore the 
treatment must be circumspect and energetic. Strict antidiabetic 
diet should be enforced. Fortunately, the young, with very rare 
exceptions, are apt to live mostly on milk, which may be given 
copiously in any form. Thus less difficulties are encountered in 
them than in adults. For these also milk, skimmed or not, forms a 
principal and beneficial part of their nutriment. Saccharin or glycerin 
may be used instead of sugar. " Gluten bread" contains too much 
starch, the "aleuronat" of the Germans about half as much as common 
bread. The medicinal treatment of the young requires some modifi- 
cations. The facility with which cerebral symptoms (" coma") are 
developed renders the persistent use of alkalies advisable (mineral 
waters), mainly sodium sulphate. Opium is tolerated in increasing 
doses. Iodoform, which I have seen render fair service in adults, 
in daily doses of from ten to twenty grains internally, is seldom 
tolerated by the young, even in proportionately small doses. Arsenic 
may be given in increasing doses a long time, the bromide as well 
as other preparations ; one drop and more of Fowler's solution, largely 
diluted, after meals, three times daily, the medicine to be increased 
gradually until from two to six drops are taken. As in every dis- 
ease which resists treatment to an unusual degree, a large number 
of other medicines have been recommended. As this book is not a 
library, but written for practical purposes only, I abstain from enu- 
merating drugs which I believe to be useless. There is one, however, 
which, in connection with everything destined to improve digestion 
and assimilation, appears to have a very favorable influence on the 
diabetic process. Sodium salicylate, with an alkaline beverage (Sel- 
ters, Vichy), has a decidedly favorable effect. A child of five years 
may take from five to eight grains, three times a day, and continue 
its use for many weeks, to advantage. Lactic acid (Cantani) may 
be tried with equal parts of sodium bicarbonate in water, one or two 
grammes a day (fifteen or thirty grains), calcium lactate in the 
same or larger doses. Extract of jambul has been powerless in my 
hands, benzosol in daily doses of a gramme or more acts more favor- 
ably. Antipyrin appeared to be a little more efficient, the feeding with 
pancreas not at all. The prognosis was always bad when oxvbutyric 
acid or renal casts made their appearance. Tuberculosis is not so 



156 DISEASES OF THE BLOOD AND CONSTITUTION 

frequent as in the adult. Fournier (Sew,. Med., 1900) publishes the 
case of a diabetic and heredo-syphilitic girl of eight years that got 
well with antisyphilitic treatment. 

Diabetes insipidus is a rare disease, but more common than dia- 
betes mellitus. A large amount of urine of low specific gravity 
(1000^ to 1005) is secreted daily. Increased micturition, great thirst, 
and emaciation are among the prominent symptoms. In some cases 
there appeared to be an hereditary influence. Syphilitic and other 
brain lesions, and injuries, have been found to explain its occurrence. 
In one case of mine (that of a girl of five years) it ceased, together 
with a copious and constant salivation, after the removal of a taenia 
mediocanellata. Inveterate masturbation and consecutive " neuras- 
thenia" appeared to be the cause of the excessive flow of urine in 
several children of from four to eight years. It ceased gradually 
with the restoration of correct habits and better general health. Of 
the remedies which have been recommended, I mention valerian, 
zinc valerianate, bromides, sodium salicylate, and galvanization of 
the head. All of these proved unsatisfactory in my hands. But I 
have seen good results, and sometimes speedy improvement, from 
the administration of ergot and atropine. In other cases they were 
absolutely useless. A child of five years may take daily, of the former 
two cubic centimetres (half a drachm) or more (ext. fluid., or the 
corresponding amount of ext. ergot., or ergotin), of the latter one- 
hundredth of a grain or less (one-half of a milligramme). More 
reliable than either has been strychnine, in three daily doses of one- 
hundredth of a grain each, or more (one-half of a milligramme). 
Zinc valerianate may be tried in daily doses of from half a gramme 
to one gramme (seven to fifteen grains). Opiates are highly recom- 
mended by Bouchut ; pilocarpine, antipyrin, and lead acetate by 
others. Fortunately, the prognosis is much more favorable than that 
of diabetes mellitus, particularly in hereditary cases. General robo- 
rant treatment, iron, quinine, strychnine, and cold water to improve 
peripheral and cardiac circulation and the tone of the nervous system. 



V 

Infectious Diseases ' 

i. Tuberculosis. 

In ten hundred and forty-five autopsies made in the New York 
Foundling Hospital (Northrup) and the Babies' Hospital, all of which 
were reported by Dr. L. Emmett Holt, tuberculosis was found in four- 
teen per cent. ; altogether one hundred and nineteen cases. These and 
similar statistics demonstrate the frequency of tuberculosis in infancy. 
From the first to the fifth year it is the same. In the above one 
hundred and nineteen cases the lungs were affected one hundred and 
seventeen times, the pleura sixty-nine, the bronchial lymph-nodes 
one hundred and eight, the brain forty, the liver seventy-seven, the 
spleen eighty-eight, the kidneys forty-six, the stomach five, the in- 
testines forty, the mesentery thirty-eight, the peritoneum ten, the 
pericardium seven, the endocardium one, the thymus three, the 
adrenals three, and the pancreas three times. 

In the young, as in the old, tuberculosis is spread either by 
mechanical transmission through cough, deglutition, and aspiration, 
or in the contiguity of tissues after having been developed in a given 
locality, or through lymph-ducts and blood-vessels. The latter, after 
having absorbed bacilli from the primarily invaded part, are liable 
to distribute them in a distant locality or all over the system in the 
shape of acute miliary tuberculosis. Most frequently the primary 
seats of the affection in the young are the bones, joints, and lymph- 
bodies (" glands"). The adenoids harbor tubercle bacilli a long time ; 
they were found in sixteen per cent, of a large number of cases 
examined. The blood-vessel walls are frequently the original seats 
of tuberculosis (peri- and endangeitis) ; that is why the first visible 
symptom of tuberculosis may be a hemorrhage, and why in tubercular 
meningitis the tubercles are found along the small blood-vessels. 
Among the latter, those of the mesentery are by no means so fre- 
quently affected as they are still reputed to be; those of the neck 

* With the exception of a very few (intermittent fever, rheumatism), all 
the diseases enumerated under this heading are also directly or indirectly con- 
tagious. As it is not my intention to systematize closely, they all appear in 
this chapter indiscriminately. 

157 



158 INFECTIOUS DISEASES 

and mediastinum are more subject to early infection through the 
neighboring mucous membranes. When tubercular they have more 
tendency to conglutination and adhesions than the benign form, which 
is more apt to remain isolated. When they have remained for some 
time it is not advisable to waste time with inunctions or injections 
of arsenic or zinc chloride. Their only safe treatment is removal. 
In case of doubt, the diagnosis may be made by the injection into a 
muscle of from one to five milligrammes of a one-per-cent. solution of 
Koch's tuberculin. 

Bacilli may be swept into the circulation through healthy epithelia, 
but the majority of infections take place in a morbid condition of the 
integuments, either epidermoid or mucous. Wounds facilitate the 
admission of bacilli (circumcision, eczema, ear-rings, medicinal sub- 
cutaneous injections, or contact — strenuously denied lately by R. Koch 
— with cattle tuberculosis; vaccination exceptionally only). The nose, 
and the pharynx when sore or ulcerated, may be equally dangerous ; 
the former the more frequently the younger the children, with their 
dirty finger-nails about their nostrils when playing on the floor, or at 
any time. The mediastinal and bronchial glands are mostly affected 
through direct inspiration into the pervious endothelial layer of the 
alveoli. 

The most common forms in which tuberculosis makes its appear- 
ance in the young are acute miliary tuberculosis, many cases of acute 
or subacute caseous pneumonia, and genuine chronic pulmonary 
tuberculosis with cavities. Caseation, however, does not always mean 
tuberculosis ; for it is also met with as the final transformation of 
pus, of carcinoma, and of typhoid infiltrations. Tubercular abscesses 
of the lungs are not at all frequent, but we see them at every age. 
While I have met with but very few cases before the end of the first 
year, they are not very rare after the sixth or eighth. Pulmonary 
tuberculosis is often accompanied or preceded by pleurisy; indeed, 
it appears probable that this pleurisy, with its frequent relapses, is the 
primary seat of tuberculosis in many. 

The most common form of pulmonary tuberculosis in the young 
is that which is developed after caseous pneumonia. It is a frequent 
result of bronchitis and catarrhal pneumonia attending measles and 
whooping-cough, and is quite generally accompanied by considerable 
changes in the neighboring lymph-bodies. It is often seen in the 
lower lobes; indeed, what is frequently suspected to be pulmonary 
tuberculosis of the upper lobes is apt to be induration, resulting from 
interstitial inflammations of infancy, which retract the corresponding 
part of the chest, exhibit diminished respiratory murmur, prolonged 



TUBERCULOSIS. CAUSES 159 

expiration, and dulness on percussion, and may last a long lifetime 
without endangering life or health to any considerable extent. 

What I said about the mode of development of these frequent 
forms points at once to preventive treatment as the principal indica- 
tion. If bronchitis, catarrhal pneumonia, measles, whooping-cough, 
and glandular diseases are frequent causes of tuberculosis, those pri- 
mary affections must be effectually treated. There is no bronchitis 
which cannot be made milder, many a case of catarrhal pneumonia 
may be shortened or rendered less dangerous, and most, perhaps all, 
cases of whooping-cough modified and shortened. In a former 
chapter I insisted upon the necessity of watching and treating all the 
self-limited diseases. The sin of omission is as grave as that of com- 
mission. And in my remarks on scrofula, to which I here refer, 
I pointed out the facility of eradicating the coming evil by removing 
the unabsorbable tumefaction of lymph-bodies. Unfortunately, the 
success of treatment in cases of acute miliary tuberculosis is so small, 
and of chronic tuberculosis so unsatisfactory, that the indications for 
preventive treatment are the more urgent. The fact of universal 
tuberculosis arising from a local source cannot be denied, having been 
proven by thousands of experimental and clinical observations. Now 
and then a case is quite demonstrable. A few years ago I had a little 
girl in my division in Bellevue Hospital who suffered from the most 
exquisite and extensive tuberculosis of the skin I have ever seen. She 
finally died of empyema and general tuberculosis. Coming from a 
fairly healthy family, she developed a glandular swelling in her right 
axilla, which was neglected, and permitted to break spontaneously 
and result in sinuses. From that place the lymphatics transported 
the accidental bacillary infection, and produced extensive ulcerations 
over the chest; metastases took place in other parts of the body. 
It is of no account to investigate whether the original affection was 
tubercular or whether the tubercular character was developed after- 
wards. This much is certain, that the child need not have died if the 
lymph-body which was primarily affected had been extirpated. 

It is unnecessary to add that tuberculosis of the bones and joints, 
so frequent in infancy and childhood, requires prompt attention and 
in some cases operative procedures. 

Among the causes of tuberculous consumption which makes its 
appearance in otherwise healthy persons, both young and old, the fol- 
lowing also are given prominence by all observers of note : insuffi- 
cient supply or change of air, absence of exercise, overwork without 
rest or vacation, monotonous food, and in larger children persistent 
mental emotions ; also trauma. Most of these sources of disease act 



160 INFECTIOUS DISEASES 

as well on the young as on the old, and may lead to infiltration before 
there is any cough, but anaemia, muscular debility, and loss of appetite 
only. Therefore tubercular infiltrations are frequently found among 
the inmates of prisons, particularly those who have been isolated a 
long time, workmen in factories, soldiers in barracks, students in semi- 
naries, children in orphan asylums and large boarding-schools, those 
attending crowded public schools and overworked in their private 
studies, besides being crippled by unwise discipline, which requires 
absolute immobility, and by loss of time or opportunity for exercising. 
It is not very probable that the occasional stately promenades of the 
young by couples — though not handcuffed, though on a Madison 
Avenue sidewalk, though attended by the good-will, moral character, 
and Argus eyes of two elderly ladies — are equivalents for the free and 
unhampered play and development of the growing organs. If it be 
a fact that there is so much less tubercular disease among hunters, 
farmers, gardeners, and sailors than among factory men and women 
of all trades, school-masters, and tailors, it is certain that rowing, 
skating, gymnastics, and tennis, even the so-called calisthenics, if prac- 
tised in the open air, would expand many a child's chest, aerate his 
blood, keep his organs vigorous, and eliminate invading poisons. 

There are many other causes or influences creating or increasing 
the possibility of tubercular invasion. A considerable predisposition 
is created by the vulnerability and fragility and cedematous infiltration 
of scrofula ; by the catarrh produced by sedentary life and foul inhala- 
tions. Koch has proved that active bacilli pass the stomach unmolested 
and may infect the intestine when this has a superficial lesion, thus 
rendering even a primary intestinal tuberculosis possible. 

While direct heredity is rare, hereditary predisposition to tuber- 
culosis is quite frequent, and is transmitted even by such parents as 
appear to be in fair health. Constitutional parental disorders resulting 
from the influence of scrofula, rhachitis, and even syphilis may finally 
prepare the children for a predisposition to tuberculosis. In such 
children every catarrh must be carefully watched. The premature 
ossification of the costal cartilages, most frequently found about the 
superior part of the chest, and the consecutive shortening of the 
sterno-vertebral diameter give rise to contraction of the thorax and 
insufficient expansibility of the (upper lobes of the) lungs. In such 
cases the aeration of the blood suffers at a very early date, catarrhal 
and inflammatory thoracic diseases are liable to become dangerous, 
and gymnastic exercises are required in early childhood. 

Direct transmission from the diseased parents to the children is 
probably more frequent than is commonly believed, and therefore 



TUBERCULOSIS. ETIOLOGY 161 

the child should not share the room and bed of the consumptive. 
Kissing must be omitted under these circumstances ; it may often be 
the cause of contagion, though, perhaps, not so frequently as, for 
example, diphtheria is transmitted in that manner. 

The origin of pulmonary consumption is uniformly, in almost all 
instances, attributed to the inhalation of bacilli. As they are deposited 
on bedding, clothing, and on the floors and walls of rooms, in hand- 
kerchiefs and towels, where they dry and are easily movable, nothing 
appears more natural than that the long-lived microbes should be 
admixed with the dust of the room, and thus inhaled. In this way the 
contagion of acute exanthemata is certainly disseminated. Tubercle 
bacilli, like everything solid, when floating in motionless air, are cer- 
tain to sink gradually, and the inference is that children are more 
liable to inhale them. This mode of propagation has been taken to be 
the principal one in pulmonary tuberculosis. To such an extent has 
this belief controlled the teachings of medical men that the rules and 
regulations of health departments concerned themselves with this 
mode of transmission only. Experiments, however, appear to prove 
that the air-currents usually found in a room are not sufficient to 
detach dry bacilli fastened with their surrounding sputum to the walls 
or floors. It is only strong currents, such as are caused by sweeping, 
beating, brushing, perhaps even by violent slamming of doors, that 
will float them. Under these latter circumstances it is certainly pos- 
sible that dry bacilli may be detached and infect those present. 

Fliigge (Zeitsch. f. Hyg. u. Inf. Krankh., vol. xxv., 1897) pub- 
lished a long series of experiments and observations which appear 
to be able to stand accurate tests. Crying, sneezing, coughing, even 
talking, detach sputum in more or less invisible quantities. Every- 
body's experience yields such instances — palpable ones — in the sick 
and well. Such moist particles, mostly infinitely small, were proven to 
remain in the air of a room five hours. Indeed, an air-current of from 
one to four millimetres a second (= twelve to fifty feet an hour) 
sufficed to float them for that length of time. In this manner the con- 
tagiousness of pulmonary tuberculosis is even more pronounced than 
by assuming the dry sputum to be the only means of conveying the 
disease, and the direct transmission from husband to wife or children, 
from the woman in childbed to her newly-born, or between patients 
in a hospital ward or sanitarium becomes almost a matter of course. 

It is evident that the newly-born cannot be safe with its con- 
sumptive mother., and just as probable that a " sanitarium," a ward, 
a hospital filled with tuberculous patients, is a hotbed of mutual 
infection, 

11 



1 62 INFECTIOUS DISEASES 

A consumptive mother must not nurse her infant because of the 
danger of immediate contagion through sputum. Besides, her milk 
may be, though it rarely is, infected like the milk of tubercular cows, 
even though their udders may not be diseased. Two cows, at least, 
out of a hundred are tubercular. Thus the least that can be done is 
to boil the milk intended for the nourishment of the infant. Koch's 
and other attempts at proving the disparity of bovine and human 
tuberculosis are not yet successful. Morphologically, chemically, and 
in their cultures they are alike or similar. The bacilli are active 
in both races, mutually, but their virulence differs even when going 
from man to man, and also when going from cattle to man after 
having been quite marked when disseminated among cattle. Thus, if 
we obey the rules I have enjoined more than forty years, the milk can 
be made more innocuous than is possible even for butter * or cheese 
obtained from such cows. These rules ought to be strictly followed, 
though there be exceptions to the universal experience. An instance 
of such exceptions is mentioned by Biedert, than whom there is no 
more reliable observer. He reports the cases of children who were 
fed a long time on the milk of tubercular cows without being attacked 
themselves. The meat of tubercular cattle is not infected (for bacilli 
are not found in muscles) and therefore not so dangerous as possibly 
their milk. But, after all, the presence of tubercular cattle in a com- 
munity is more than simply objectionable. Its dangers exist, though 
they may have been exaggerated. That is why Koch's tuberculin, 
which failed as a cure, has proved a preventive, inasmuch as it re- 
veals the presence of tuberculosis by the elevation of temperature 
following its subcutaneous injection. 

Among the causes of consumption monotony of food has been 
enumerated by many. It is evident that it is of little account in the 
cases of infants or children, whose habits are plainer and digestive 
functions more adapted to simpler and more uniform articles of diet. 
Most of these, while in health, are satisfied with milk, cereals, and 
but little meat. Sweet cream may be added to the milk, but more 
than a few ounces are not digested through the course of a day. 
Cod-liver oil acts not only through its fat. During the afebrile con- 

* Butter does not seem to be very dangerous, for neither Schuchardt nor 
Rabinowitsch (Koch's Institute) found tubercle bacilli in eighty samples of 
butter taken from different stores and markets. Twenty-three of them caused, 
in guinea-pigs, alterations resembling, but not exactly like, tuberculosis 
(Deutsche med. Woch., August 5, 1897). Many similar investigations have 
since proved that the bacilli change in virulence, which decreases or increases 
according to changing circumstances, culture-media, etc. 



TUBERCULOSIS. CLIMATE 163 

dition and chronic emaciation, over-alimentation, introduced by 
Debove, may be tried to advantage, while the insufficiency of gastric 
digestion may be stimulated by the administration of artificial gastric 
juice (pepsin with muriatic acid) and mild stomachics (gentian, nux, 
diluted alcoholic beverages) and orexin tannate in three daily doses 
of from one to three grains (0.06 to 0.2). When exercise cannot 
be taken to a sufficient extent, or is contraindicated by the neces- 
sity of enforcing temporary, but absolute, rest, massage, according 
to S. Weir Mitchell's plan, will take its place. During fever, over- 
alimentation is to be stopped ; it deranges digestion and increases 
bodily heat. Alcoholic stimulants will at that time often take its 
place to advantage. While they do not act well in certain over-irri- 
table natures with over-sensitive hearts, and in haemoptysis, they are 
good stimuli for the general system, diminish perspiration, and act 
favorably in diarrhcea. 

In the treatment of tuberculosis no single factor is a cure by 
itself. The quality of the air alone will not cure the sick any more 
than a certain mixture of salts and water in a mineral spring, or some 
known chemical relation of albuminoids and carbohydrates in an article 
of food. Insufficient clothing and bedding, unheated rooms, draughty 
halls, indigestible food, strong coffee and tea, hot cakes and cold 
drinks, late hours, lively hops, brass instruments and pianos disturb- 
ing midnight rest, kill as many, in proportion, in Colorado, Florida, 
Southern France, and Italy as in New York. Unfortunately, we 
know too well that our patients believe they have done enough for 
their physician (or themselves?) when they have followed his advice 
to change climate. In this respect, too, it is true that those who speed 
over the sea are changing their sky, but not their spirit.* It should 
never be forgotten that the change of climate is mostly a negative 
remedy, and cannot be expected to offer more than the possibility 
of favorable external circumstances. Some caution should be ob- 
served in regard to places with an old and established reputation. A 
mountain resort of deserved great repute will change its character 
when the village changes into a big manufacturing place, with soot 
and sulphuric acid in place of a clear atmosphere. 

Moist air is a better conductor of warmth than dry air. Thus 
loss of temperature is more rapid in moist air than in dry air. Dry 
air, therefore, may be very much cooler, and is still better tolerated 
in spite of its lower temperature, and affords more protection. 
Haemoptysis appears to be a frequent occurrence at the times and 

* " Coelum non animam mutant qui trans mare currunt." 



1 64 INFECTIOUS DISEASES 

i 

seasons of increasing - atmospheric moisture (spring). According 
to Rohden's researches, a rapid increase of the percentage of water 
in the blood is frequently sufficient to produce a hemorrhage. Thus 
the drinking of large quantities of water ought to be avoided, and no 
residence be selected for a patient subject to haemoptysis where the 
atmosphere is very moist. Dry altitudes, such as those of New Mexico, 
have given me good results in pulmonary hemorrhage. At all events, 
no place should be selected where the percentages of moisture in the 
air are liable to change rapidly. The uniformity of an insular climate 
is, for that reason only, not so dangerous to those who have bled from 
their lungs. Still, dry air and a higher scale of the barometer are 
preferable. 

The diversity of opinions in reference to the climato-therapeutics 
of phthisis resulted from the circumstance that the indications were 
not distinctly understood. Neither cold nor warm, neither dry nor 
moist, air by itself is a remedy. Warm air does not cure, but it enables 
the patient to remain out of doors. The temperature should be 
uniform, sudden currents of air avoided, and the atmosphere free of 
microphytes. At an altitude of sixteen hundred feet their number 
is greatly reduced (Miquel), there are but few at a height of two 
thousand six hundred feet (Freudenreich), very few at six thousand, 
and absolutely none at twelve thousand feet, provided the parts are 
not, or but little, inhabited. Over-population of elevated villages and 
cities diminishes or destroys their immunity. In the factories of the 
Jura Mountains, with a great working population, at an altitude of 
three thousand five hundred feet, tuberculosis is frequent. 

Protection against sudden gusts of wind and rapid changes of 
temperature is an absolute necessity. The elevated valleys or rather 
recesses of mountains (Colorado) deserve their reputation in pul- 
monary diseases. Davos is dusty, windy, and exposed to frequent 
changes of temperature during the summer, and must not be advised 
for that season. Woods are warmer in winter, cooler in summer ; 
so is the ocean. Both, therefore, deserve their reputation in the 
chronic ailments of the respiratory organs. 

Not the thinness of the atmosphere, but its purity, both on plains 
and on mountains, is the requisite, and a high percentage of ozone. 
The latter is developed under the influence of intense light, the pres- 
ence of luxuriant vegetable growth, particularly of evergreen trees 
(Terebinthinacese), and the evaporation of large sheets of water. 
Thus, ozone is found at moderate or high altitudes, in needle-wood 
forests, and near or on the ocean. 

In the general hygienic treatment of tuberculosis the skin requires 



TUBERCULOSIS. HYGIENE. DRUGS 165 

particular attention. Sudden changes of temperature, which strike 
the surface suddenly and work their effects on internal organs by 
reflex, — " colds," — in spite of the modern superciliousness of those 
who deny any pathological change unless by the exclusive work of 
bacteria, will always hold their places in nosology. The skin must 
be both protected and hardened. Wool, or wool and cotton, must be 
worn near the skin, the feet particularly kept warm, no wet or moist 
feet permitted, undergarments changed according to season and the 
alternating temperatures of days or weeks and every night and morn- 
ing. It is of the greatest importance to impress upon the minds of 
the very poorest that they must not wear during the day what they 
have slept in. Still, while protection is to be sought anxiously, vigor 
and strength are to be obtained by accustoming the surface to cold 
water. The daily morning wash may be warm in the beginning, and 
become gradually cooler; alcohol may be added to the water in the 
beginning (alcohol alone is unpleasant by its withdrawing water from 
the tissues), or salt. The temperature of the water being gradually 
diminished, the same treatment can be continued during the winter, 
with a pleasant sensation of vigor. The subsequent friction with 
coarse bathing towels sends a glow over the surface and through the 
whole body; it is desirable that, as much as possible, the patient per- 
form it himself. The easiest way to start the habit is by washing, a 
short sponge- or shower-bath will take its place soon, and a cold 
plunge will be borne, even by the weak, afterwards. 

It has become fashionable with many to feign a contempt for 
internal medicines in the treatment of tuberculosis, pulmonary and 
other. I am glad that I cannot share their opinion. Thus, for in- 
stance, I look upon arsenic as a powerful remedy in phthisis. It 
was eulogized as early as 1867 by Isnard, in a monograph, for its 
effect both in malaria and consumption, in both of which he explained 
its usefulness through its operation upon the nervous system. He 
asserted that suppuration, debility, emaciation, vomiting, diarrhoea, 
and constipation would improve or disappear under its administration. 
The doses of arsenous acid used by him in the eases of adults 
amounted to from one to five centigrammes (one-sixth to five-sixths 
of a grain) daily. 

Arsenic is certainly a powerful remedy. It is known to act as 
a poison and a strong caustic. It prevents putrefaction, though as 
an antiseptic it ranks even below salicylic acid. It acts favorably 
in malaria, chronic skin diseases, and maladies of the nervous system, 
and has considerable, and sometimes unexpected, effects in the treat- 
ment of lymphosarcoma and sarcoma. It is also said to increase 



1 66 INFECTIOUS DISEASES 

sexual desire and power, and in animals physical courage. Thus 
there is a variety of effects the intrinsic nature of which may be 
found, uniformly, in the action of the drug on the function and 
structure of the cells, which, though varying in different organs, 
have the same nutritive processes. Arsenic has a stimulating effect 
on cell-growth. In small and frequent doses it stimulates the devel- 
opment of connective tissue in the stomach, in the bone and peri- 
osteum, everywhere ; in large doses, by over-irritation, it leads to 
granular degeneration. Like phosphorus, arsenic builds in small 
doses, destroys in large ones. By fortifying the cellular and all 
tissues, both fibres and cells, it enables them to resist the attack of 
invasions, both chemical and parasitic, or to encyst or eliminate such 
enemies as have already penetrated them. Thus it finds its principal 
indication in the peculiar fragility of the blood-vessel walls resulting 
in pulmonary hemorrhage. 

The doses should be small. A child a few years old may take 
two drops of Fowler's solution daily, or a fiftieth or fortieth of a 
grain of arsenous acid for weeks or months in succession. This 
amount may be divided in three doses and administered after meals ; 
the solution should be largely diluted. There is no objection to 
combining it, according to necessity, with stimulants, roborants, or 
narcotics, and to giving it for an indefinite period, unless the well- 
known symptoms of an overdose — gastric and intestinal irritation 
and local oedema — make their appearance. But they seldom will, 
particularly when small doses of opiates are judiciously added to 
them. In almost every case, perhaps in every one, it is desirable to 
administer it in conjunction with digitalis. 

In the vertebrate animal, digitalis increases the energy of the 
heart muscle and its contraction ; thereby it increases arterial pressure 
and diminishes the frequency of the pulse. By increasing arterial 
pressure it favors the secretion of the kidneys, improves the pul- 
monary circulation, empties the veins, thereby accelerates the flow 
of lymph and of the tissue fluids, and exerts a powerful influence 
on the metamorphosis of organic material, — that is, general nutrition. 
Besides, what it does for the general circulation and nutrition it also 
accomplishes for the heart muscle itself. The blood-vessels and 
lymph circulation of the latter are benefited equally with the rest. 
Thus digitalis, while called a cardiac stimulant, contributes largely 
to the permanent nutrition and development of the heart. This effect 
is not only of vital importance to the economy of the system on 
general principles, but an urgent necessity in view of the fact that 
there appears to be a relative undersize of the heart, either congenital 



tuberculosis, digitalis, guaiacol 167 

or acquired, in cases of pulmonary tuberculosis ; and there is certainly 
such a predominance of the size of the pulmonary artery in the young, 
particularly over the aorta, that the normal succulence of the lung 
becomes pathological quite readily when the insufficiency of the heart 
muscle tends to lower arterial pressure within the distributions of 
the pulmonary artery. The selection of the preparation to be admin- 
istered is not always an indifferent matter. The infusion and the 
tincture are not always well tolerated by the stomach; digitalin, not 
being a soluble alkaloid but a glucoside, is not reliable in its effects 
and not of equal consistency and strength ; a good fluid extract, or 
the extract, is borne well and may be taken a long time. A child 
five years old may take about two minims of the former daily, more 
or less, for weeks and months, or its equivalent in the shape of the 
extract (two-thirds of a grain daily) ; the latter can easily be given 
in pills, to be taken in bread or jelly, and combined with any medi- 
cines indicated for special purposes, such as narcotics, or nux, or 
arsenic, or iron; the latter to be excluded in all feverish cases or in 
all cases while there is fever. So long as there is no urgent necessity 
for a speedy effect, digitalis will suffice by itself ; as a rule, it does not 
operate immediately in these small doses. The addition of strophan- 
thus, or sparteine, or caffeine, all of which are speedily absorbed and 
eliminated, and exhibit their effects rapidly and without the danger or 
inconvenience of accumulation, will prove advantageous in many 
cases. 

Creosote has been introduced into practice, both for inhalation and 
internal administration, since 1877. No direct influence on bacilli 
should be looked for. What it can do is to better the condition of the 
patient. It will often improve appetite, combat putrefaction, thereby 
facilitate assimilation, and (sometimes) relieve diarrhoea. The doses 
vary. Almost incredible doses have been given (from ten to fifteen 
cubic centimetres = two to four drachms daily, and more to adults). 
Probably from two to ten drops daily is a dose for children, which, 
according to their ages, may be administered for a long time. Creo- 
sote carbonate, almost tasteless and easily borne, is a proper substi- 
tute, one or two drachms (4.0 or 8.0) or more daily. Neither ought 
to be persisted in when the appetite does not improve within a reason- 
able time, nor during a pulmonary hemorrhage, nor when the urine, 
which requires frequent examination, contains albumin. 

This dozen years I have replaced creosote by guaiacol, recom- 
mended by Schiiller, Sahli, and others, which constitutes nearly sixty 
per cent, of the very best creosote in the market. A child will readily 
take from six to fifteen drops daily (according to age) in from three 



1 68 INFECTIOUS DISEASES 

to four doses. It is best taken after meals, in sugar-water, in milk, or 
in cod-liver oil. There are but few who object to it. Those who do 
may take one of its salts, the benzoate (benzosol), salicylate, cinnamyl- 
ate, or carbonate. Of these I have mostly employed the last, also the 
first. They are (almost) tasteless and readily taken, in doses of as 
many (or more) grains as the fluid guaiacol in drops. In guaiacol I 
have been less disappointed than in any other internal remedy admin- 
istered in pulmonary tuberculosis, cod-liver oil not excepted. It is a 
good stomachic, appetite and digestion improve under its use, the 
cough gradually becomes looser, less purulent, the rales more mu- 
cous, and the body weight is apt to increase. While creosote is not 
well tolerated in the stage of cavities and hectic fever, guaiacol is not 
only borne, but appears to exert its beneficial influence even in that 
condition. There are but few patients who do not derive some benefit 
from its internal use. Externally it has been recommended to subdue 
hectic fevers ; for that purpose the chest and abdomen are painted 
with the pure guaiacol several times daily. It has the advantage over 
creosote of not being contraindicated either in hemorrhage or in 
renal complications.* 

I do not fear that it will be replaced by ichthyol (sulpho-ichthyo- 
late of ammonium), which has been eulogized by Colin, Scarpa, Le 
Tanneur, H. Fraenkel, and others. Adults (children in proportion) 
are expected to take 0.25 = four grains in a capsule before every 
meal, or from twenty to forty drops four times a day of a solution in 
equal parts of distilled water. In spite of the admixture of aromatic 
oil, it has a bad taste and will be administered with difficulty. 

After the failure of Koch's tuberculin several antitoxins and 
serums made their appearance. The tuberculocidin of Klebs and 
the serum of Maragliano (which is said to contain no antitoxin) have 
not conquered the universal good opinion of the profession any more 
than the cantharidin recommended by Liebreich, or the cinnamic acid 
recommended by Landerer, who asserts that it stimulates and causes 
leucocytosis, and that leucocytes penetrate the tubercular deposits, 
which are then absorbed or cicatrize. Koch's new tuberculin is intro- 
duced as containing the insoluble parts of the bacilli in finest mechani- 
cal disintegration, while the old was said to be a glycerin extract of 
the bacilli. What it will do remains to be seen. A patient (adult) 
in Bellevue to whom I gave increasing doses, beginning with the 
minute doses recommended (one-fifth of a milligramme of the fluid) 



* See my paper in International Medical Magazine, November, 1892, and 
Transactions of the Climatological Association, 1892. 



TUBERCULOSIS. ANTISEPSIS 169 

and rising to three minims, showed no reaction whatsoever, though 
the autopsy proved the presence of extensive tuberculosis. Nor are 
the exaggerated promises held out for the old tuberculin repeated 
in the new. This is said by Koch to exert its influence in the very 
beginning of the morbid process in the lungs, when there is no com- 
plication at all with streptococci or septicaemia, and when the tem- 
perature of the body does not exceed 38 C. (100.4 F.). It is readily 
seen that under such circumstances there will be but few cases of 
pulmonary tuberculosis in children in whom, because of the extreme 
difficulty of the diagnosis at that age and in that stage, the remedy 
can be administered with any show of justification. The tuberculin 
promised * by Behring has not materialized. 

Other remedies have been used in great numbers. Specifics have 
been recommended, and symptomatic treatment was resorted to. The 
success of the latter depends on the judgment of the individual prac- 
titioner. No text-book or essay can teach more than general principles 
and their adaptability to the average case, and the measures to be taken 
in a number of exceptional occurrences. The indications for the use of 
narcotics, stimulants, expectorants, and febrifuges will change accord- 
ing to the cases and their various phases. In every case the necessity 
may arise for antipyrin, phenacetin, sodium salicylate, or quinine, 
never for acetanilid (antifebrin), which is a strong anilin poison and 
apt to change, even in small doses, haemoglobin into methaemoglobin. 
It may be necessary to decide the question whether the administration 
is to be made through the mouth, rectum, or subcutaneous tissue, or 
how their effects are to be corrected or combined. I have often found 
that a hectic fever was not influenced by quinine, or antipyrin, or 
sodium salicylate ; but the combination of the first with one of the 
latter frequently had a happy effect. 

The change in our pathological views, or rather the addition of a 
new factor to our etiological knowledge, has directed our attention 
to the antisepsis of the respiratory organs. To destroy bacteria is 
not necessary in order to make them relatively harmless. It is impos- 
sible to kill the bacillus without killing the normal cell, but very mild 
antiseptics suffice to stop the efficiency and proliferation of the parasite. 
Thus we can hope that the future will teach us how to reach the 
destructive process in the lungs. For the present, however, neither 
the inhalation of hot air nor of hydrochloric acid, nor the rectal in- 
jections of hydrogen sulphide have done any good. Turpentine 



* Fifteenth Congress for Internal Medicine, Berlin, session of June 10, 
1897. 



iyo INFECTIOUS DISEASES 

inhalations are frequently beneficial by loosening, in some cases 
diminishing, expectoration from suppurating surfaces, as they have 
the effect, mixed or not with eucalyptol or other disinfectants, of 
destroying the fetor of pulmonary gangrene. The inhalations of com- 
pressed air, or the breathing of normal air while the body is sur- 
rounded by rarefied air, will prove advantageous in chronic processes 
where the object is to expand the contracted lung tissue. Inhalations 
of ozone may render better services in future than A. Caille acknowl- 
edged in 1892 (Arch, of Ped., August, 1892). Later personal com- 
munications of his express themselves very hopefully (p. 74). 

Operative procedures are less indicated in pulmonary tuberculosis 
of children than even in that of advanced age. The opening of a 
superficial large and copiously secreting abscess is a rare indication, 
for the latter seldom occurs except in the semi-adolescent; and if it 
does, the prognosis is anyway absolutely fatal. Besides, the dissemi- 
nation of the tubercular process is so general in the lungs of the young 
that not more than a slight temporary improvement can be expected 
of an operation. 

Among the localizations of tuberculosis in children that in the 
larynx is not frequent. A complication with emphysema of the neck 
and face has been reported. According to Heinze, laryngeal tuber- 
culosis is not produced by contact, but through the medium of the 
blood. But the expectorated masses are undoubtedly a frequent 
cause of the local infection, which is preceded by hyperemia with 
injured or detached epithelium. Besides nodulated inflammatory 
swellings in the mucous membrane, submucous tissue and glands, 
sometimes even between the muscles, there are small granulations 
and ulcerations on the cords, with universal catarrh, cedema, and 
phlegmonous destruction. The symptoms are those of catarrh and 
ulceration, and depend on the locality and severity of the lesion. In 
some cases the diagnosis of pulmonary tuberculosis could not be made 
in the beginning, and that of the local affection was based on the 
duration of the ailment, the persistence of the fever, and the steady 
emaciation. At first the laryngoscopy examination revealed catarrh 
only, and afterwards ulceration and infiltration. The local treatment 
is that of the catarrh, — inhalation of warm vapors, steam, turpentine, 
carbolic acid, ammonium chloride ; poultices around the neck ; opiates 
at bedtime. The spray with lactic acid and the application of iodo- 
form have served me less well than a daily spray of a solution of one 
part of silver nitrate in from two to five hundred parts of distilled 
water. Stronger solutions are rather harmful. The pain produced 
by ulcerations located on the epiglottis and arytenoid cartilages is 



TUBERCULOSIS. LARYNX. PHARYNX. INTESTINES 171 

somewhat relieved by the application (brush or spray) of potassium 
bromide, morphine, or cocaine, or of an appropriate mixture of two 
or three of them. Gleitsmann reports cures obtained by lactic acid. 

The air around patients suffering from laryngeal phthisis may be 
moist; but it is a mistake to believe that it must be warm. Cold air 
is warmed before it enters the larynx and lungs, provided it enters 
the respiratory tract through the nares. Only when it is admitted 
through the mouth it remains somewhat cool when reaching the 
larynx. Thus the nares must be kept as normal as possible, and 
competent, no matter with what difficulties ; nor will open windows 
interfere with the comfort of the patient, provided draught is avoided. 
That can easily be accomplished by screens or otherwise. 

Ulcerations of the tongue and pharynx are painful, sometimes 
to such an extent as to require frequent attention. A well-directed 
spray, as mentioned above, of one part of silver nitrate in two hun- 
dred of distilled water (glass to be of neutral, blue, or black color), 
administered once a day, will be found serviceable in average cases. 
When ulcerations are localized a drop of the same solution may be 
applied with a glass rod. Some are so bad as seriously to interfere 
with deglutition. I have been obliged to use a cocaine spray before 
every meal, or a drop of Magendie's solution (very effective!) on 
the tongue. For the purposes both of cure and of prevention the 
nose and nasopharynx should be irrigated copiously and frequently 
with a warm salt solution (6 to 1000). 

Tubercular ulcerations of the intestines may descend to the 
rectum; in that case the local symptoms, and mainly the tenesmus, 
may be alleviated by warm injections containing gum acacia or 
bismuth, with or without opiates. Food and drink must be warm ; 
bismuth may be given in doses of from two to ten grains every 
hour or two, so as to form a protection to the sore intestine. Tan- 
nin I have not seen do much good. Naphtalin sweeps the whole 
length of the tract and acts favorably as a disinfectant. I have seen 
almost immediate improvement after its use. From four to ten grains 
may be given daily (two to six decigrammes). Now and then the 
stomach rebels against it ; in that case, resorcin, in doses of from 
one-fourth to one grain (fifteen to sixty milligrammes), in powder 
or in solution, may be given for the purpose of disinfection from three 
to eight times daily. Though it be very soluble, it certainly is effective 
to a certain extent. All of them may be combined with bismuth, or 
lead, or opium. Hydrargyrum bichloride cannot be relied upon for 
any effect in the lowest parts of the intestinal tract because of its 
great solubility, the necessity of great dilution, and its ready absorba- 



172 INFECTIOUS DISEASES 

bility. Salol in several daily doses of from one to five decigrammes 
(one and a half to eight grains) is palatable and effective. 

Fistula in ano is not such a rare occurrence in children as I was 
led to believe many years ago. No matter whether it is an accidental 
complication, or the bacilli are conveyed to the parts through the circu- 
lation, or the fistula is the result of the presence, in the faeces, of bacilli 
and of their action on defective epithelium, or the hands of the child or 
of the nurse convey the infection from the mouth, or the linen, or the 
floor to the anus, practice has changed entirely during the last decade. 
The axiom that in a consumptive patient fistula must not be interfered 
with has given way to a more rational theory and sounder practice. 
The sooner they are operated upon and treated the better. 

Pulmonary hemorrhages are not of such frequent occurrence 
as in adults, but I have observed them in children of from three to 
eight years. The prognosis is always serious, and rather bad when 
hemorrhage is followed by rise of temperature, which means either 
secondary broncho-pneumonia or disseminated tuberculosis. A single 
attack of haemoptysis in a girl of eleven years proved fatal by suffo- 
cation. The patient should rest upon the diseased side, to prevent, 
as much as possible, the aspiration of blood, with or without ba- 
cilli, into the healthy part. The application of a lump of ice or an 
ice-bag over the locality of the hemorrhage acts favorably, either 
through the direct influence of the cold temperature or the reflex 
contraction of the bleeding vessels. Subcutaneous injections of the 
fluid extract of ergot, or ergotin in glycerin and water, are very apt 
to give rise to induration or abscesses ; thus it will be left to the prac- 
titioner to decide in an individual case whether that risk may be 
taken. Its constituents, cornutin and sclerotinic acid, should not be 
recommended on account of their rapid decomposition and irritating 
effect. Morphine may be given internally also for the purpose of 
relieving the patient's symptoms, both objective and subjective. If 
it cannot be swallowed well, the proper quantity of Magendie's solu- 
tion, not diluted with water, is readily absorbed through the mucous 
membrane of the mouth or throat. The internal administration of 
ergot may be supported by that of mineral acids and digitalis. Of 
the latter, a single dose of from two to five grains (one to three 
decigrammes), or its equivalent, acts well. Dilute sulphuric acid is 
both efficient and palatable; ten or fifteen drops in a tumbler of 
(sweetened) water will readily be taken to advantage. Fluid extract 
of hydrastis, from ten to twenty drops frequently repeated, in an 
emergency, or hydrastin hydrochlorate in doses of one-one-hundred- 
and-twentieth grain (0.0005), or stypticin in repeated doses of one- 



TUBERCULOSIS. HEMORRHAGES. NIGHT-SWEATS 173 

thirtieth grain or more (0.002) is an effective remedy. Lead acetate, 
in doses of from one-sixth to one-half of a grain, every hour or two, 
according to age and the severity of the case, is preferable to tannin ; 
it can be given with morphine or digitalis, or both. The patient 
requires absolute rest and encouragement, and must be induced to 
make long, forcible inhalations, and told to suppress the cough as 
much as possible. To relieve it opiates may be required. For the 
purpose of stopping hemorrhages the inhalation of the sesquichloride 
of iron (1 to 100) has been recommended. As it was not expected to 
enter the bronchial tubes, its effect was presumed to be by reflex action. 
I have tried it a number of times, like many others, but cannot recom- 
mend it. Ligature of the extremities tight enough to constrict the 
veins, but not the arteries, is sometimes quite effective, but should not 
be continued longer than half an hour at a time. Among the best 
haemostyptics are calcium chloride, several grains every few hours in 
emergencies, eight or twelve grains daily for a long time as a prevent- 
ive; the dry extract of suprarenal capsule, from three to five grains 
every few hours in an urgent case; a sterilized solution (two per 
cent.) of gelatin in salt water (6 to 1000), of which several ounces 
(from fifty to one hundred cubic centimetres) may be injected under 
the skin. But extensive lesions of a large blood-vessel cannot be 
expected to be greatly influenced by any of these remedies. Abso- 
lute rest (opiates) will contribute to the spontaneous coagulation of 
extravasating blood and the relief of the hemorrhage. 

Night-sweats, the result of toxins, are not uncommon in the 
tubercular phthisis of children from five to twelve years of age. 
They are favorably influenced by the same remedies which are apt to 
relieve the adult ; such are sponging with vinegar and water, or 
alum in vinegar and water. A powder of salicylic acid three parts, 
zinc oxide ten, and amylum ninety, or salicylic acid three, amylum 
ten to twenty, and talcum eighty to ninety, dusted over the perspiring 
surface from a powder-blower, is quite beneficial and soothing. For 
internal administration dilute sulphuric acid, ten or fifteen drops in 
a tumblerful of water, taken gradually, is found enjoyable by a great 
many. A single dose of atropine sulphate, from one-half or one- 
quarter of a milligramme (one-one-hundred-and-twentieth or one- 
two-hundred-and-fiftieth grain) at bedtime, or agaric acid (from four 
to ten milligrammes), or duboisine (from one-half to one milli- 
gramme) , or camphoric acid in doses of from five to ten centigrammes 
will bring relief. When there is an indication for opium, it may be 
combined with any of them. When the digestion is good, a fair dose 
of quinine (from three to six grains), with or without extr. ergot. 



i 7 4 INFECTIOUS DISEASES 

(the same dose), or extr. ergot, fluid, (from one scruple to half a 
drachm), deserves a trial when for some reason or other the above 
remedies are discarded. 

2. Syphilis. 

The nutrition of an infant suffering from hereditary syphilis 
is attended by great difficulties. Many of the mothers who con- 
tracted syphilis either before conception or during gestation are 
anaemic in addition to their constitutional ailment ; thus their milk 
is certain to be incompetent. The former class is very numerous, 
although women syphilitic before conception are apt to miscarry and 
have no living children. The latter class (those who contracted 
syphilis during their pregnancy) is not quite so large, fortunately; 
but still the question will come up now and then whether the baby 
of a woman who acquired syphilis in the course of her pregnancy 
should be nursed by her or not. The theoretical answer to this ques- 
tion has been this : that the baby may be permitted to nurse if it have 
been infected already, but must not be put to the breast if still healthy. 
That answer is no answer ; for in most cases of syphilis thus acquired, 
and even in the majority of hereditary syphilis (derived mostly from 
the father, syphilitic before conception), the first symptoms of the 
disease in the infant are visible after some, or many, weeks only. 
Thus, nobody knows whether the newly-born is infected or not. If 
such a baby be puny, feeble, and in poor general health, nobody would 
have the courage to deprive it of its mother's milk. Artificial feeding, 
as frequently carried on, would be a death-warrant. That is why 
such a baby ought to be nursed by its mother, and, if exceptions be 
permissible in favor of the puny, and the puny be expected to thrive 
on its mother's milk, the vigorous baby's chance will be the better. 
Therefore I certainly advocate the baby's nursing at the breast of the 
mother who acquired syphilis during pregnancy, no matter whether 
or not the symptoms of the disease be visible in the baby. Mean- 
while, both mother and baby must be subjected to a thorough and 
prolonged antisyphilitic treatment. 

The same baby must not be put to the breast of a healthy wet- 
nurse, no matter whether or not symptoms have made their appear- 
ance in the baby, or whether or not the baby has been subjected to 
an antisyphilitic treatment. For the nurse must not be exposed under 
any circumstances, without at least having been made fully aware of 
the risk she is running. 

The mother of a baby infected with hereditary syphilis (by the 
father) is herself either syphilitic or not. If the latter, she is immune 
as regards her infant, — that is, she will not be infected by her nursing 



SYPHILIS. DIET. PREVENTION 175 

syphilitic infant. In both cases she must and may nurse. For if 
syphilitic herself, she will not render the case of her infant more 
serious ; if not, she cannot transmit a disease she has not herself.* In 
neither case can she be infected by the diseased infant. For safety's 
sake, however, both mother and child must be treated. 

As said before, no baby, either hereditarily syphilitic or suspected 
of hereditary syphilis, must be put to the breast of a healthy wet-nurse. 
Syphilis contracted through the infection of the nipple is liable to be 
as destructive as that which attacks physicians through their fingers. 
Such a wet-nurse must be forbidden to nurse altogether, or permitted 
only with a full knowledge of the circumstances, and directed, if she 
accept a place after all, to nurse through an artificial nipple. Mean- 
while, the syphilitic or suspected baby must undergo an antisyphilitic 
treatment. If he be only suspected, but for good reasons, the treat- 
ment should not be postponed until positive symptoms may have made 
their appearance. For mercurial treatment is a less grave interference 
in the young than in the old, and nothing can be more reprehensible 
than the opportunity given to constitutional syphilis to obtain full 
sway. 

From what has been said of the many contraindications to the 
infant being brought up at the breast, it follows that artificial feeding 
must often be resorted to. This circumstance impairs the prognosis 
considerably, and claims the best knowledge and soundest judgment 
of the well-informed practitioner. Improved methods of artificial 
feeding, however, improve the prognosis. 

The prevention of hereditary syphilis is based in part on that 
of syphilis in general. Public hygiene is not benefited, as they try 
to do in New York, under the guidance of a combination of ignorance 
and hypocrisy, by disseminating venereal diseases throughout the 
whole city ; but by wise superintendence and control of the " social 
evil." A syphilitic person must not marry. When a man has con- 
tracted syphilis he ought to be treated methodically two years, and 
three years ought to elapse after the last symptoms of syphilis were 
noticed before he marries. During pregnancy, when there is a sus- 
picion, both man and woman ought to be treated. 

Preventive treatment is required both on the paternal and mater- 



* " Colles's law." There is also " Profeta's law," according to which chil- 
dren born in good health of syphilitic parents are immune against syphilis. 
There are cases, however, in which children of syphilitic parents acquired 
syphilis afterwards, and others of persons who, while carrying the traces of 
hereditary, acquired a new syphilis. 



i;6 INFECTIOUS DISEASES 

nal side. Syphilitic endometritis leads mostly to miscarriage ; when 
the embryo and foetus survive, the newly-born exhibits syphilis at 
once. Women infected during pregnancy may, or may not, infect 
their offspring, according to the time of their own primary and 
secondary symptoms. It is impossible to be sure. In all of these 
cases, and mainly also in those of women, not themselves syphilitic, 
who have been impregnated by syphilitic men, a thorough and pro- 
tracted antisyphilitic treatment is required. Both mercury and iodides 
reach the foetus through the maternal circulation. For practical 
reasons, for women with habitual abortion, in whom the diagnosis 
cannot positively be made, I advise and practise mercurial treatment. 
It has given me better successes, even in those cases in which thirty 
or forty years ago, according to Simpson, I gave alkaline (potassic 
chlorate) treatment. Most cases of hereditary syphilis, however, are 
derived from the father. It is he who must undergo a strict and 
effective treatment for the purpose of extinguishing the calamitous 
malady. 

The medicinal treatment of hereditary syphilis requires the several 
preparations of mercury, in many cases iodides also. Mercurial prepa- 
rations are well borne by infants and children. Stomatitis and gin- 
givitis are very exceptional occurrences. The indications, modes of 
administration, and doses of the remedies depend, to a great extent, 
on the locality or organ affected, whether skin, mucous membrane, 
subcutaneous tissue, lymphatic glands, muscles, bones, the viscera of 
the thoracic or abdominal cavities, the nervous system, or the sensory 
organs ; and on the time at which the first symptoms become per- 
ceptible. In the majority of cases this takes place between the fifth 
and eighth weeks of life. Then the nose, lips, and anus exhibit 
rhagades ; these fissures are apt to be quite painful ; the skin is 
covered with roseola, the palm of the hand and sole of the foot with 
efflorescences ; the complexion becomes sallow without being uniformly 
so at all times, for changes and a certain degree of intermission are 
observed. After a while maculous, squamous, and papulous erup- 
tions make their appearance, pustules and vesicles spring up and 
terminate in ulcerations, gummata appear in the skin. This form 
permits of a fair prognosis, particularly in the cases of infants reared 
at the breast. The treatment can be carried out slowly and system- 
atically. It consists in the internal administration of calomel ; doses 
of from one-twentieth to one-sixth of a grain can safely be given 
three times a day for months in succession. If in any case diarrhoea 
set in, and no fault be found in the food administered or in the con- 
dition of the digestive organs, which may have been impaired by other 



SYPHILIS. TREATMENT 177 

causes, from a twentieth to a twelfth of a grain (three to five milli- 
grammes) of Dover's powder may be added to each dose. 

Other preparations which have been recommended are the bichlo- 
ride and the cyanide in doses of from one-thousandth to three- 
hundredth of a grain several times daily. The green iodide of 
hydrargyrum is not so well tolerated as calomel, and the oxidulated 
tannate of mercury, recommended by Lustgarten, does not seem to 
offer any advantages. As these pages, however, are being written 
for practical guidance, and not for the elaboration of the history of 
therapeutics of infant syphilis, I can but advise the use of calomel as 
effective and sufficient. The use of the blue ointment has been 
eulogized under the impression that the internal administration of the 
drug might lead to digestive disorders. As inunctions made in the 
usual way were found to irritate the skin (oleates are objectionable 
for that reason alone), it was recommended to apply it to a sheet of 
soft leather surrounding the knee, and to secure its slow absorption 
by the spontaneous movements of the baby's extremities. Thus the 
treatment is left to a great extent to the patient, and the actual dose 
cannot, to say the least, be determined upon or even estimated. Wider- 
hofer modifies inunctions by applying a mercurial plaster of the size 
of the hand, which he changes once a week, to the intrascapular 
region, and praises his results. When the skin is badly affected, from 
one to two grammes (fifteen to thirty grains) of mercuric bichloride 
may be added to the daily bath of the infant. This external treat- 
ment may be continued for weeks. 

A similar treatment is required in those cases in which an 
infant or child (in the latter in larger doses) has acquired syphilis 
in one of the many ways in which the disease can be contracted. The 
ritualistic sucking out of the circumcised prepuce has given rise to 
syphilis as it has produced tuberculosis ; syphilitic nipples of a mother 
or nurse, vaccination, kissing, the brushing of the throat with infected 
instruments, in older children sexual contact, are much too frequently 
causes of syphilis. This acquired syphilis of infancy and childhood 
is apt to run a swifter and more deleterious course than the same dis- 
ease in most adults. Therefore it may become necessary to add to the 
above treatment such methods as have proved most effective and 
speedy in urgent cases of hereditary syphilis also. 

These urgent cases run a different course from those briefly 
sketched above. In many of them the diagnosis of hereditary syphilis 
can be made immediately after birth. General pemphigus of the 
surface of the newly-born is not a symptom of syphilis, but localized 
pemphigus of the palms of the hands and the soles of the feet is. It 

12 



178 INFECTIOUS DISEASES 

is seldom the only symptom, though it often requires close obser- 
vation not to overlook the affections of the internal viscera and the 
bones. The latter are often the seat of syphilitic disintegration ; in 
the costo-cartilaginous junctures Wegner studied the changes caused 
by syphilis, which resemble very much those of early rhachitis. Liver, 
spleen, pancreas, and lungs exhibit two different changes, either gum- 
mata or interstitial proliferations of the connective tissue. In the 
liver these are mainly met with along the blood-vessels and bile-ducts, 
and are capable of producing jaundice and even total and permanent 
obstruction of the ducts in the foetus or the newly-born. An early tume- 
faction of the spleen was the first prominent symptom in one of my 
cases. Twice I have seen both testicles the seat of syphilitic tumors 
in the newly-born. The blood-vessels suffer at an early period. 
Syphilitic arteritis, first described by Heubner, gives rise to conges- 
tions and hemorrhages ( petechias and purpura) on the skin and serous 
membranes, in the intestines and kidneys, in the cranium, and in the 
thymus gland ; and many early brain symptoms and sudden deaths 
of the newly-born are due to intracranial hemorrhages, oedema, and 
softening from the same causes. Nor have the sensory organs of the 
newly-born any immunity. C. S. Bull has met with iritis and choroi- 
ditis. 

These are the cases in which the systematic calomel treatment 
is insufficient. In them it is of the utmost importance to get the sys- 
tem immediately under the influence of mercury. With or without 
the internal treatment, subcutaneous injections of mercury must be 
made at once. The subcutaneous injections of calomel, which I, like 
many others, have tried in the adult, have given me, contrary to many 
assertions of their sponsors, so much trouble in the shape of abscesses 
or indurations that I cannot bring myself to recommend them in the 
newly-born, with its spare connective tissue. But a solution of from 
one to two grains of hydrargyrum bichloride in an ounce of distilled 
water (1 to 240) is quite innocuous. It can safely be injected once or 
twice daily, in doses of from one-hundredth to one-fiftieth of a grain 
(one to two milligrammes). That treatment I have followed in many 
an urgent case more than thirty years, and can safely recommend it. 
No reliance should be placed on mercury given to the mother or nurse, 
for its elimination through breast-milk is an uncertain process and an 
unknown quantity. 

When the bones and glands suffer at an early period, the mercu- 
rial treatment ought to be combined with the administration of the 
iodides. Potassium iodide may be given to the infant in doses of from 
five to ten grains (three to six decigrammes) daily. Under all circum- 



PARAS YPHILIS 179 

stances, the treatment must be persisted in for many months after the 
disappearance of the very last symptoms. In spite of that the consti- 
tutional disorder may break out again, either in its original form or as 
an osteitis only, leading either to caries or to sclerosis ;. or as a cerebral 
or spinal affection. That is why, when the symptoms have disappeared, 
recovery should not be taken for granted. After it seems to have been 
accomplished, the patient may be let alone for a month or two. Then 
the treatment ought to be resumed for the same reason that makes 
renewed treatment obligatory for adults; he should not be con- 
sidered safe until years have elapsed without a symptom. Syphilitic 
arteritis, meningeal exudation, or gummatous tumor may lead to 
ptosis, nystagmus, facial paralysis, hemiplegia, hemichorea, or idiot- 
ism, to myelosclerosis or transverse myelitis. A syphilitic inflam- 
mation of the labyrinth with Meniere's symptoms has been observed 
in a girl of five years by Knapp, and interstitial keratitis, also reti- 
nitis, appears to result from syphilis quite often. A painless otitis 
media was noticed by Fournier. In all such cases the energetic 
treatment with mercury and iodides combined must be resumed and 
continued for an indefinite period. But it has often appeared to me 
that syphilis will do more than produce these unmistakable symptoms. 
There are many cases of " scrofula," chronic lymphadenitis, and 
rhachitis which — with no other causes to account for them — appear 
to point to previous syphilis not completely extinguished. In a num- 
ber of my own cases I have personal knowledge of such a history. 
Such cases not only explain the fact that many old authors recom- 
mended mercury in " scrofula" and " rhachitis," but also that there 
are some in which that treatment is indispensable. Only lately I 
had to deal with chronic cervical adenitis, mainly of the left side, 
and pulmonary infiltration of the left upper lobe, in a baby of two 
years. They resisted the usual treatment for more than a year before 
the suspicion of their syphilitic nature was roused and the history 
of the disease elicited. Six weeks of a mercurial and iodide treat- 
ment have worked a miraculous change in the local and general con- 
dition. Besides, there are children of five or more years that, without 
a possibility of arriving at a local diagnosis, remain puny, under- 
weight, undersized and anaemic, spiritless and feeble. This constitu- 
tional incompetency is sometimes one of the results of parasyphilis 
(Fournier) ; neither arsenic, iron, nor oxygen will do good in many 
of them. A protracted antisyphilitic treatment will fatten and 
strengthen them. 

More than a conscientious and persistent antisyphilitic treatment 
is rarely required. Exceptions may be cardiac lesions ; syphilitic myo-, 



180 INFECTIOUS DISEASES 

peri-, or endocarditis, or several of these forms combined, may require, 
occasionally, digitalis or very feeble doses of an opiate; brain and 
cord lesions bromides or chloral ; and fevers an occasional antifebrile, 
for a brief period. Fever may be very puzzling, though it is more 
frequent in acquired than in hereditary syphilis. In tne former it is 
quite frequent, — in from twenty to thirty-three per cent, of the cases, 
in the eruptive stage, rarely before the fortieth day. It should be 
suspected in both forms of syphilis because, though it was mentioned 
as early as 15 14 by de Vigo, and very often since, it is often not 
looked for. 

3. Intermittent Fever. 

In older children the type is the same as in adults. We have 
acute and chronic forms, the quotidian, tertian, and quartan types. 
There are the same results and anatomical lesions. There are the 
general anaemia, — in infants and children most rapid and detri- 
mental, — the splenic tumor, the hemorrhages, and the amyloid de- 
generation. 

It is only in newly-born infants and very young children that 
the diagnosis becomes difficult. In them the type is mostly quotidian. 
Besides, the attack may come at irregular times. Not infrequently 
it is seen in connection with catarrhal diseases, which appear to 
create a susceptibility to the poison. The chills are not easily diag- 
nosticated. Perspiration is very frequently not profuse. The tumor 
of the spleen can be recognized by palpation at a late period only, 
but the temperature is apt to be very high. Sometimes the attack 
is not recognized because of the first symptom being a convulsion. 
Masked cases are not uncommon ; intermittent pneumonia, neuralgia, 
even paralysis have been noted. Dr. L. Emmett Holt observed inter- 
mittent torticollis and bronchial asthma, but the peribronchial lymph- 
bodies have never been found to contain plasmodia, — a proof, it ap- 
pears, that malaria is not inhaled (or possibly that the endothelial 
layers of the alveoli, which are believed to pass tubercle bacilli, refuse 
access to protozoa). Attacks of vomiting, also diarrhoea, have been 
noticed. For all these reasons the diagnosis is often not made. On 
the other hand, the diagnosis of malaria is made improperly in too 
many instances. In every doubtful case the blood should be examined 
for plasmodia. The subsequent severe anaemia, as blood-cells are 
rapidly destroyed, is liable to be very obstinate. Among the sequelae 
glomerulo-nephritis, also the hemorrhagic form, is not uncommon. 
Immunity there is, but it cannot be produced. As preventive meas- 
ures, the drinking-water should be boiled; nursing mothers should 



INTERMITTENT FEVER 181 

be cured quickly, for their milk may transmit the fever; malarial 
regions should be avoided; the child should sleep under mosquito 
netting. 

Quinine ought to be given, if the attacks come at regular intervals, 
in a single dose, three or four hours before the attack. That is the 
time when the plasmodia are small and movable. If the attacks 
occur at irregular periods, it is better to divide the total amount 
of quinine in three or four doses, to be given through the day. In 
the first case a dose of five grains (three decigrammes) will suffice 
for a child of three years ; in the second case eight or ten grains 
(five decigrammes) will be required. If possible, quinine should not 
be given during the high temperature. When this lasts long, with 
dangerous symptoms, it should be modified by a few doses of phe- 
nacetin or antipyrin, — never acetanilid. 

It is not always easy to give quinine because of the taste. A 
solution ought not to be tried for the same reason. One part of 
quinine sulphate may be given with forty parts of elixir simplex, but 
in every case the dose must be mixed just before it is taken. Euqui- 
nine is almost tasteless ; its doses are like those of quinine. The neu- 
tral quinine tannate is tasteless, and may be given as a powder ; but for 
one part of the sulphate two and a half of the neutral tannate should 
be administered. The sulphate may be given mixed in chocolate 
— older children will take it greedily — or in coffee or syrup of coffee. 
When it cannot be given internally, rectal injections may take the 
place of the internal administration. No acid must be added to the 
solution ; therefore very soluble preparations only must be used, — for 
instance, the bromide, the muriate, the bisulphate, the carbamide 
(bimuriate with urea) ; or suppositories may be given, but with less 
positive effect than that of other modes of administration. Inunction 
of quinine has been recommended a great many times. The ointments 
made, as usual, with animal fats have very little effect. When it 
is impossible to use any other method, quinine may be dissolved 
and mixed with fat and a larger quantity of lanolin; but even in 
this case the dose which really penetrates the skin and enters the 
circulation cannot be determined. A subcutaneous administration 
of quinine becomes necessary when no other can be resorted to or 
when an immediate effect is required. The best preparation for the 
purpose is the carbamide, which will dissolve in from four to six parts 
of warm water, and give rise to less induration than we are liable 
to meet with when using the other salts. When recovery appears 
to be established, it is advisable to give a weekly dose of the drug 
for some time. 



1 82 INFECTIOUS DISEASES 

In the chronic form arsenic, with occasional doses of quinine, 
is the principal remedy, as in the cases of adults. A child of three 
years may commence with one drop of liquor potassii arsenitis 
(Fowler) three times a day, to be administered as detailed in a former 
chapter. The liquor sodii arsenatis of the Pharmacopoeia may take 
its place in those cases in which the stomach is very irritable ; also the 
preparation of the same name introduced by Pearson, which is ten 
times milder than the official preparation, and must be given in 
proportionate doses. If the solutions of arsenic be not well tolerated, 
arsenous acid may be given instead. It may be administered in 
the shape of pills in doses of from one-hundred-and-fiftieth to one- 
hundredth of a grain, three times a day, or more, to children of three 
years, or it may be administered as a powder in combination with 
other medicines. It may safely be mixed with bismuth, for the dis- 
agreeable odor emanating from persons taking bismuth, which has 
been attributed to arsenic contained in it, really belongs to a minute 
dose of tellurium inseparable from some specimens of bismuth in 
the market. All these preparations of arsenic may and should be 
given for many weeks or months. Constitutional symptoms belong- 
ing to an overdose I have seen more frequently when using Fowler's 
solution than any of the other preparations; but, after all, they are 
rare. 

Tincture of eucalyptus has been given in acute, and particularly 
in chronic, cases. It renders good service now and then in doses of 
from ten to twenty-five drops, three or more times a day. Methylene- 
blue is unreliable. 

As there are very obstinate cases in the adult, so there are in 
children. In them, too, the spleen may remain large and the attacks 
return indefinitely. These are the cases which try the endurance 
of the patient and the patience of the physician. In them I have 
seen excellent results from the use of ergot these more than forty 
years. Ergot may be given as fluid extract, and a child of three years 
may take from a scruple to a drachm (four cubic centimetres) every 
day for weeks in succession, or a corresponding quantity of the ex- 
tract of ergot, — that is, from three to ten grains (two to six deci- 
grammes) every day, either in mixtures or, for older children, in 
pills. I have noticed in a good many cases in which the fluid extract 
was not borne at all, that the extract of ergot, when given in the 
latter shape, was easily tolerated. In many cases the combination of 
ergot with quinine or (and) arsenic is advisable. 

Subsequent anaemia demands the syrup of iodide of iron and other 
medicinal and hygienic treatment. Polyneuritis has been observed 



TYPHOID FEVER 183 

after malaria. It may be due to malaria toxins (proven to exist) or 
to those which are produced by the destruction of numerous erythro- 
cytes. 

4. Typhoid Fever. 

Though occurring in the first few weeks of life, it is rare in the 
first year, not uncommon after the second. Most cases are met with 
between the sixth and the twelfth years. 

Its danger may come from many causes : from previous ill health 
and anaemia, which may depend on a feeble constitution, hereditary 
syphilis, chronic ailments of the organs of digestion, of respiration, 
and of circulation ; from the intensity of the invasion, which is some- 
times manifested by a high initiating temperature and early septic 
symptoms ; from an unusually high temperature ; from insufficient 
power or actual failure of the heart ; from diarrhoea, intestinal hemor- 
rhages, perforations, and local or general peritonitis ; from complica- 
tions such as meningitis and nephritis ; and, finally, from consecutive 
diseases. 

The uncertain symptoms of the first days render the diagnosis 
difficult. Sometimes it is made by exclusion only. If a characteristic 
curve of the typhoid fever, the tongue of infectious fevers, diarrhoea, 
tympanites, large spleen, roseola (appearing between the sixth and 
the eleventh days), and a positive diazo and Widal test are present, 
it is not doubtful. It may be difficult to detect a pneumonia even after 
days, but after a while local symptoms will permit a differentiation. 
Trichinosis has been mistaken for it (Osier in Am. Jour. Med. Sci., 
1899, No. 3) ; its pain, oedema, muscular swelling, leucocytosis up 
to 17,000, and large percentage of eosinophile cells (from forty-eight 
to sixty-eight) should secure a diagnosis. Miliary tuberculosis may 
be mistaken for a severe case of typhoid fever, but when it is localized 
in the cerebral meninges, the slow and irregular pulse, vomiting, con- 
stipation, and diminished action of the kidneys secure the diagnosis 
of tubercular meningitis. There are, however, cases in which the 
general symptoms do not seem to agree with the elevation of the 
temperature and other symptoms. I know of no other serious and pro- 
tracted disease in which the patients so often declare themselves to 
be well in spite of marked objective symptoms to the contrary. 
Widal's test and the diazo reaction, though not always positive, and 
found in other diseases also, and mostly available in the second week 
only, are suggestive of the presence of typhoid fever. The demon- 
stration of the bacillus, if well distinguished from bacterium coli com- 
mune, is proof positive, but it is not yet feasible in general practice. 



1 84 INFECTIOUS DISEASES 

Preventive treatment has led to very good results. Many houses 
and towns which were the seats of endemic typhoid fever have been 
rendered immune by improving the sewerage and the general condi- 
tion of the neighborhood. For typhoid fever (the bacilli being long- 
lived) and dysentery can be traced positively to exhalations of privies 
and sewers, while with regard to other diseases we can only say that 
animal exhalations from the same sources may create a predisposition 
by impairing the general health, but are not able to produce specific 
diseases independently of other influences.* When the drinking- 
water is suspected, it ought to be boiled. No raw milk should be 
given. The fseces of the patient must be disinfected, though there 
be no diarrhoea, by crude muriatic acid, or a five-per-cent. solution of 
carbolic acid, or by copperas. The thermometer with which rectal 
temperatures are taken should be disinfected after every application. 
The sick should be isolated when they suffer from typhoid diarrhoea, 
and the practice, still prevalent in hospitals, of placing many typhoid 
patients in general wards should be abolished. The nurse attending 
a typhoid case should disinfect her hands immediately before turning 
to another patient. 

Can typhoid fever be aborted? or, in other words, can its first 
stage be interrupted? An affirmative answer to this question has 
often been given, but it is difficult to prove the correctness of the diag- 
nosis in an alleged case of typhoid fever that lasted a few days only. 
While with our present knowledge we cannot believe that the pro- 
liferation of the toxin floating in the blood may be interrupted by 
antifermentative treatment, it is certainly either justifiable or advisa- 
ble to try the effect of otherwise not injurious antifermentatives, such, 
perhaps, as creosote or hydrochloric acid, if it be only for their 
effect on the intestinal tract. As regards the early administration 
of a large dose of calomel, its effect is notoriously good, no matter 
whether it acts as a disinfectant directly on the bacilli or whether 
it simply relieves the intestinal tract of the poison introduced and 
in multiple proliferation. A child of three years may take a dose 
of three or four grains (two or three decigrammes) ; a child of eight 
years one of seven or eight grains. While the purgative effect of 
the calomel can be obtained by simply introducing the powder into 
the mouth, there to be absorbed, it is better in this case to let 
it be swallowed. It can safely be given during all of the first week 



* A. Jacobi, The Production of Diseases by Sewer Air, Transactions 
of the Congress of American Physicians and Surgeons, 1894, and N. Y. Med. 
Journ., 1894. 



TYPHOID FEVER. FEEDING 185 

of the disease. When, as frequently, there is constipation during 
the course of the disease, calomel is no less beneficial, but then it 
should be given in smaller doses ; not enough to cause diarrhoea. 
During the diarrhoea of the second or third week it should not be 
given. 

With regard to the general treatment of the typhoid fever of 
children, we are equally liable to injure either by overactivity or by 
neglect. The so-called expectant treatment has its great dangers 
when persevered in by those who make it their invariable rule; it is 
safe in the hands of those only who have learned to treat the sick 
rather than the sickness. The air in the sick-room should be cool, the 
windows open. Draughts, it is true, should be avoided, but screens 
around the bed will permit the opening of both windows and doors. 
The bed-sheets must be smooth ; four or eight safety-pins will fasten 
them to the corners and sides of the mattress. At an early period the 
whole surface ought to be washed often either with water or with 
alcohol and water. The hair, when long, ought to be cut. The 
children should be allowed plenty of water. Those who are liable 
to have dry lips and tongue must be made to drink a small quantity 
of either water or dilute muriatic acid in water, ten minims to the 
tumblerful, every ten or twenty minutes. Fissures around the lips 
or in the tongue ought to be washed with a saturated solution of 
boracic acid, or, when bleeding, should be painted once a day with 
a mild solution of silver nitrate (not more than one per cent.), the 
lips also with an ointment consisting of boracic acid and lanolin. 

Very much depends on the mode of feeding. No solid food must 
be given. Boiled milk, milk on the Rudisch plan, broths, farinaceous 
decoctions, strained. For older children, one or two soft-boiled eggs 
daily, diluted in broth, either the whole of them or the white only; 
meat-juice, albumoses. As a general thing, more albuminoids than 
carbohydrates ought to be given. The food should be such as will 
be digested in the stomach and small intestines, and not encumber 
the colon. If necessary, a small quantity of pepsin and muriatic acid 
may be given with it. Peptones may be given, but they must not 
form anything like the exclusive diet. I allow no solid food until 
ten days have elapsed after apyrexia sets in. 

The tendency to complications with bronchitis requires frequent 
changes in the position of the patients. They ought to be turned 
from their backs to their sides every few hours, and back after a 
while; otherwise they ought not to be moved too much. Particular 
care ought to be taken not to raise them too often. Physical and 
mental rest is an absolute necessity. Pleuritis is an ominous compli- 



1 86 INFECTIOUS DISEASES 

cation and should be looked for early. Defecation must take place 
in the recumbent posture. They must not be permitted to strain. 
Some tepid antifermentative injections into the bowels should be 
made daily (thymol I to 3000). 

The danger arising from high temperatures varies in different 
patients. Their injurious influences depend, from a clinical point 
of view, on many causes, foremost among which are both individual 
susceptibility and the length of time during which the child is exposed 
to its internal heat. A high temperature lasting but a certain time, 
and alternating with either an intermission or a remission (as, for 
instance, intermittent or relapsing fevers), may not prove dangerous 
at all, and may not require any treatment; but the frequent repe- 
tition of elevated temperatures, or their long duration, demands inter- 
ference. Therefore they ought to be measured at least four times 
a day, particularly as typhoid fever is apt to yield two daily exacer- 
bations and remissions. 

Continued high temperatures in the course of typhoid fever or 
intense fever at the very beginning of the disease require treatment. 
In them the frequency and quality of the pulse, which in the average 
case is relatively slow, and the functions of the nervous system are 
seriously disturbed at an early period. Under the influence of a short 
cold bath both temperature and heart-beats diminish, arterial pressure 
increases, and the intellect becomes clear ; it has a peculiarly favorable 
influence on the infant and child. In them the surface is relatively 
larger than in adults, and the cooling by radiation is more rapid and 
intense. Sometimes the circulation is disturbed and the surface tem- 
perature not readily restored afterwards. It may happen that the in- 
ternal temperature rises while the external blood-vessels are contracted 
by cold, and the internal organs become engorged. In these cases a 
hot bath is more liable to restore radiation from the skin and reduce 
internal heat. Whenever no immediate reaction takes place — mainly 
about the extremities — after the child has been taken from the cold 
bath, this must not be repeated, and the feet kept thoroughly warm. In 
such cases a warm bath is infinitely milder and more useful ; or when 
the temperature is high and threatening, a cold pack — as detailed in 
a former chapter — around the trunk is preferable. At the same time 
the feet must be kept warm and a stimulant given. Cold applications 
to the heart are frequently sufficient to reduce the temperature. In 
such cases as develop sopor at an early period, together with high 
temperatures, the pouring of tepid or cool water over the head, or 
head and shoulders, is very beneficial. The contraindications to the 
use of the cold bath are general debility, weakness of the heart, cold 



TYPHOID FEVER. TYMPANITES 187 

extremities, a cold surface complicated with high internal temperature, 
and intestinal hemorrhage. 

The medicinal agents used to reduce temperatures in typhoid fever 
are sodium salicylate, antipyrin, phenacetin, and quinine. All of the 
medicines mentioned above must be given carefully. To avoid a 
possible debilitating effect on the heart, a general or cardiac stimu- 
lant should be given at the same time. All of them may be given in 
small doses, and frequently repeated, when the remission is not 
marked ; but, as a rule, an occasional larger dose is preferable. Anti- 
pyrin can be administered internally, through the rectum, or, if 
urgently demanded, subcutaneously. A child of three years may take 
from five to ten grains (one-third to two-thirds of a gramme) a day, 
in from two to four doses, two of which have often to be given in 
close proximity (the second after an hour or two hours). Phenace- 
tin may be given in doses of from one to three grains (five to twenty 
centigrammes), twice or three times a day, to a child of the same age. 
The administration of quinine follows, as a rule, the method detailed 
above, but in typhoid fever it is liable to disorder the stomach and 
intestine and produce diarrhoea or tenesmus. Its time is the remis- 
sion, its single dose from five to seven grains (half a gramme or less), 
once a day or every other day, and its best indication the persistence 
of the splenic enlargement in the course of the third week of the dis- 
ease. The combination of quinine with one of the other antifebriles 
yields good results quite often when one of them does not appear to 
be sufficient, in the same way that the effect of a tepid bath combined 
with an antifebrile is now and then quite astonishing. Euquinine 
may take the place of quinine. 

The intestinal tract is the seat of many dangers. Tympanites 
and meteorismits depend on the paralytic condition resulting from en- 
teritis only, or from enteritis and peritonitis. The latter is either local, 
and corresponds with the local ulcerations, or general. Cold appli- 
cations are serviceable. Enemata of ice-water will sometimes do good ; 
or of an aromatic infusion (chamomile, anise, fennel, catnip) ; some- 
times of turpentine, half a teaspoonful or a tablespoonful mixed with 
the fluid (water or soap and water) . The introduction of a large cathe- 
ter with one or more additional eyes may relieve the lowest part of the 
intestine of gas. Puncture of the inflated intestine by means of a 
small syringe (" hypodermic") is not dangerous in cases in which 
it is not required. Where it would be of service, however, — that is, 
in the very worst forms of intestinal paralysis, with intense and dan- 
gerous inflation, — it is injurious ; for in these cases the elasticitv 
of the intestinal wall is gone and the small punctures remain open. 



1 88 INFECTIOUS DISEASES 

I have seen faeces entering the abdominal cavity through them, and 
fatal peritonitis, of my own making. 

Diarrhoea, when moderate, need not be interfered with at any 
period of the disease. It is probable that the initial dose of calomel 
prevents it in a great many cases. When it is copious, such remedies 
as pass through the whole length of the intestine will render good 
service either by their soothing or disinfectant effect. Bismuth sub- 
gallate or subcarbonate, from a scruple to a drachm daily (one to 
four grammes), is valuable. Bismuth salicylate does not always 
act kindly in the stomach. Naphtalin, from half a grain to a grain 
(three to six centigrammes) every two hours, when tolerated by 
the stomach, — in most cases it is, — improves the odor of the evac- 
uations and diminishes their number. In many cases I have given 
it for its disinfectant action from the very beginning of the fever. 
Salol, in doses of from one to three grains every two hours, has a 
similar effect. Mild doses of opium may be added, from half a minim 
to a minim of the tincture, every two or four hours. Resorcin is 
better tolerated than either, but it does not pass the whole tract. 
Cold applications, covered with rubber cloth and (or) flannel, must 
be changed every twenty or thirty minutes. Warm applications 
may take their place when the little patients are quite feeble and 
anaemic. Among the astringents, when required, I prefer lead ace- 
tate in small doses of five or more milligrammes each. Both tannin 
(gallic acid is milder) and alum are liable to annoy the stomach. 

Constipation is much more frequent in our cases of typhoid fever 
in both the young and old than in the descriptions of the books, both 
European and copied. When not too persistent it may not prove 
dangerous ; for most children have not suffered from constipation 
before the disease began, and accumulation of faeces is not a very 
prominent feature in them. When there is peritonitis it must not be 
wantonly disturbed. In no case should strong purgatives be given. 
Castor oil in small doses may become necessary; half a teaspoonful 
or a teaspoonful every few hours may then be given, or small repeated 
doses of calomel, from a quarter to one-half of a grain. Rectal 
injections of tepid water, with six per mille salt, with, or mostly 
without, turpentine or thymol, will be all that is required in most 
cases. But it is a good rule — a very good rule — to enforce by ene- 
mata a daily movement, or even several when the evacuations are 
fetid. In diarrhoea they will disinfect, in constipation they will re- 
lieve. It should be remembered that the condition of the faeces need 
not correspond with that of the intestines. There may be constipa- 
tion while there is ulceration, and ulceration without symptoms, so 



TYPHOID FEVER. PERITONITIS. HEMORRHAGES 189 

that even perforation may take place without previous diarrhoea. 
On the other hand, there are cases of typhoid without intestinal 
lesions (Hodenpyl, Opie and Bassett), or these are very slight or 
very few in number, perhaps in the appendix only, or there are mere 
infiltrations of the solitary glands and Peyer's plaques. 

Peritonitis requires absolute rest, opium in large doses, internally 
or subcutaneously, together with stimulants (caffeine, alcohol, musk), 
cool or cold (warm in very bad, apparently moribund, very anaemic 
cases) applications to the abdomen, hot ones to the feet. Perforations 
may be met with the same treatment, but the results of laparotomy 
when performed within a few hours after perforation have proved 
encouraging. 

Hemorrhages are not so frequent in the typhoid fevers of the 
very young as in those of adults, because of the mostly superficial 
character of the ulcerations. But in older children the intestinal 
lesions are apt to be as grave as in more advanced periods of life. 
No food should be given for some time, drink in small quantities 
only, but repeatedly. Applications of iced cloths, an ice-bag, or a 
lump of ice — to lose no time — to the right hypochondrium. They 
may be moderately heavy, for compression may have a local influ- 
ence. Hot injections into the rectum have no styptic effect; iced ones 
may act through reflex. Internally, alum or lead, one-quarter or 
one-half grain (fifteen or thirty milligrammes) or more, every hour 
or two hours, with opium and digitalis. Ergotin, or fluid extract 
of ergot, and other preparations of the drug which were asserted 
to be innocuous, I have seen to give rise, frequently, to indurations 
or abscesses after their subcutaneous administration. Their effect 
is mostly questionable. I have seen gangrene over a large surface 
after their use, and pyaemia several times. In the case of a little 
girl I had to incise about sixty metastases in the course of two months 
before she was saved from a pyaemia which resulted from a single 
hypodermic injection. The internal administration of ergot may be 
tried when the condition of the stomach permits it. To combat the 
imminent fatal termination I have been compelled to perform trans- 
fusion of blood in the case of an adult ; she recovered, but died of 
a relapse on the fiftieth day. Injections of large quantities of steril- 
ized salt water into the subcutaneous tissue (6 to 1000) yield most 
surprising and life-saving effects in urgent cases of utter exhaus- 
tion. 

The condition of the heart cannot but influence the course of the 
disease, its complications and consecutive disorders. It cannot help 
being enfeebled by a serious and protracted disease such as typhoid 



190 



INFECTIOUS DISEASES 



fever; still, how far this feebleness will extend cannot be predicted. 
Besides, it depends to a great extent on causes not exactly connected 
with the infection itself. Among these accessory causes are original 
— congenital — debility and chronic heart diseases previously con- 
tracted. Moreover, the infection itself with its accompanying fever 
is apt to give rise to an acute myocarditis or to granular degeneration 
of the heart muscle. Among the symptoms of debility of the heart, 
which may easily lead to complete heart-failure, are pallor of the 
skin and of the mucous membranes, purplish and cyanotic hue, par- 
ticularly of the lips, ears, and finger-ends, mottled appearance of 
the surface depending on venous stagnation in the small blood-vessels, 
cold extremities and nose, slow or, more commonly, frequent pulse, 
which, moreover, is arrhythmic, and a heart-beat the sounds of which 
are. either split or embryocardiac, — that is, exhibiting equal intervals 
between the first and second sounds. In other cases the danger is 
indicated by the close proximity of the second sound to the first to 
such a degree that the former is scarcely audible. 

The brain symptoms belonging to heart-failure are those of 
anaemia. When beginning to treat them, we should not forget the 
possibility of an error in the diagnosis of the condition, which may 
be quite serious, because the signs of anaemia and hyperemia are in 
many respects the same. However, the general indications for the 
treatment of heart-failure may be laid down in a few rules, the first 
of which refers to prevention. As heart feebleness must be expected 
in every protracted disease, and failure feared in many, we ought to 
act, as a matter of prevention, exactly as the surgeon does in his 
operations. Before the times of antisepsis and asepsis there were 
performed a great many operations that did not lead to sepsis or 
erysipelas. Indeed, these mishaps were the minority, perhaps a small 
one at that. But they did occur, and that is why no surgeon would 
at present perform any operation, either serious or trifling, without 
measures to secure asepsis. If he neglected them, he would justly 
be held responsible for any mishap in the shape of erysipelas or 
pyaemia. Now, the certainty of cardiac debility and the danger of 
heart-failure are much more threatening in an infectious fever than 
in those complications of convalescence after an operation. There- 
fore in no case of typhoid fever ought the heart to be left to fight 
its own battle unaided, with the chances of being overexerted (with 
possible dilatation from that cause), fatigued, or exhausted. The 
doses of cardiac stimulants cannot be stated categorically, but the prin- 
ciple must be established that it is a good rule to give moderate 
amounts of digitalis, strophanthus, convallaria, sparteine, caffeine, 



TYPHOID FEVER 191 

or an alcoholic beverage. The particulars have been stated in former 
chapters and must be left to the judgment of the practitioner. 
Digitalis and strophanthus may derange the stomach after a while; 
digitalis may not act quickly enough under certain circumstances; 
in such a case sparteine sulphate, which is readily dissolved, ab- 
sorbed, and eliminated, in doses of one-half of a grain or more (0.03 
or 0.05) every two or three hours, may be given for some time. 
Caffeine must not be given when there is hyperemia of the brain. 
Caffeine sodio-benzoate and sodio-salicylate dissolve readily in two 
parts of water, and are reliable aids in sudden attacks of heart- 
failure, in hypodermic administration. (Dose: from twenty to thirty 
centigrammes.) Camphor internally, in doses and according to 
methods described above, will answer well in either the presence or 
absence of pulmonary complications. In cases of emergency its 
subcutaneous administration works admirably in sweet almond oil, 
in a twenty-per-cent. solution. 

Ammonium carbonate disorders the stomach more frequently 
than camphor is apt to do. Ammonium muriate has no stimulant 
effect at all. Brandy and whiskey, when of good quality and well 
diluted (at least one in four or five parts of water or milk), hold the 
first rank. That they should, while sufficient doses must be insisted 
upon, not be given at all unless indicated, and omitted as soon as no 
longer wanted, is self-understood. Still, I know that they are often 
continued too long, and the occurrence of cirrhosis of the liver in 
children who exhibited no other cause of the disease except the pro- 
tracted use of alcohol for alleged medical reasons is by no means 
unheard of. Champagne will often take the place of brandy and 
whiskey when speedy stimulation is required, or Tokay, Madeira, 
sherry, or a California wine when the former are objected to because 
of their taste. When there is diarrhoea, opium given in small doses — 
perhaps one-quarter of a minim of the tincture every hour or every 
two hours to a child of three years — will act both as a cardiac stimu- 
lant and astringent. Of musk as a powerful stimulant I have seen 
the best possible results. Nitroglycerin in doses of a two-hundredth 
or one-hundredth of a grain, repeated frequently until four or six 
doses have been taken, will be found a vigorous remedy when, while 
the heart is still acting, the arterial pulse is flagging. 

Whatever medicines may be found desirable, the child should be 
kept absolutely quiet. In a recumbent posture it must remain, as 
a rule; thus the food has to be given, thus it has to be carried to 
the window or into the open air, if circumstances permit. Many a 
case that looked like being near extinction within the four walls 



192 INFECTIOUS DISEASES 

will exhibit a wonderful improvement on the lawn or under shade- 
trees. 

Besides, the surface must be kept warm. It is principally the 
extremities which require external heat. A hot bath, without or 
with an aromatic addition, and hot injections into the bowels will 
do a world of good in many a desperate case of collapse, always 
provided the manipulations required are absolutely gentle and not 
exhausting. 

To relieve inflammatory complications of the brain in typhoid 
fever the hair ought to be cut very short, the head kept high and 
washed frequently, or water may be poured over it while the body 
and throat are protected by an India-rubber cloth. The application 
of ice-water directly to the head in small children is not tolerated 
for a long time. It may give rise to collapse, and should be watched 
carefully. While the head is to be kept cool, the feet must be kept 
warm. Mustard foot-baths and hot applications to the feet, cold 
water or an ice-bag to the heart, an ice-bag around the neck, will 
be found very comfortable. When there is the slightest brain com- 
plication not depending on the infection itself or anaemia, no alcohol 
should be given, no opium, and no caffeine, though they may appear 
indicated by the condition of the heart. It is rarely necessary to 
resort to local depletion when the meningitic symptoms are quite 
clear. In these cases leeches may be applied to the mastoid process 
or, better still, to the septum narium. When the brain symptoms 
belong to the infection alone or to anaemia, opium is, however, well 
tolerated, and relieves sleeplessness and the general irritability. Now 
and then codeine may take its place, or amylene hydrate, chloral 
hydrate, or sulphonal. Sometimes the subcutaneous injection of 
morphine — one or two minims of Magendie's solution — will give 
instantaneous relief. Warm bathing will prove beneficial in such 
conditions of general excitability. In these cases the use of cold 
must be carefully avoided. It is understood that all such measures 
are meant for exceptional cases only. Mild cases will take care 
of themselves without them. But insidiously chronic diseases of the 
brain and spinal cord, such as insanity or ataxia, may come on. 
Neuritis should be looked for. An ounce of prevention may save 
your patient. 

During convalescence sudden changes in feeding must be avoided. 
I repeat, it is dangerous to give other than fluid diet before the tenth 
day after the fever has disappeared. After that time white meats, 
plain puddings, and jellies may be added. Raw fruit must not be 
given under any circumstances. Patients should not be taken out 



TYPHOID FEVER. CONSECUTIVE DISEASES 193 

of bed sooner than a fortnight after their fever has disappeared. 
Older children should not be allowed to read. No visitors should 
be admitted during the early part of convalescence; neither the 
heart nor the brain bear any strain. The body temperature and the 
movements should be watched very carefully, for relapses may occur. 
Such relapses are very frequently the result of improper food, which 
will irritate the intestinal ulcerations, the process of whose healing- 
is thereby interrupted. The greatest care must be taken in those 
cases in which the spleen, when tumefied during the progress of 
the disease, does not nearly assume its normal size about the 
middle of the third week. When it remains large, a relapse may 
be looked for. 

The large number of consecutive diseases which may result from 
typhoid fever is ample proof that all such measures are by no means 
superfluous ; multiple abscesses of the muscles, osteitis, epiphysitis, 
and arthritis are not very uncommon after typhoid fever. Noma is 
now and then seen, but it is only just to state that epiphysitis and 
arthritis are not so frequent after typhoid fever as, for instance, after 
scarlet fever, and noma not so frequent as after measles. But pur- 
pura may remain behind. Parotitis is not very uncommon. Thrombi 
in the extremities are sometimes met with. Erysipelas, laryngeal 
perichondritis, and cutaneous gangrene are by no means rare. But 
it is certain that many of these occurrences can be avoided if greater 
care be taken during the progress of the disease. The kidneys suffer 
in typhoid fever as they do in most infectious fevers, and frequently 
at an early stage. The majority of such consecutive cases of nephritis 
are mild and run a favorable course. Bad cases will be considered 
below. 

Among possible complications — not only as the pretext of an 
uncertain diagnosis — we frequently hear of that with malaria. 
Whether typho-malaria is a disease sui generis, as Manson says he 
has seen in China, may be uncertain ; but there is no reason why 
Plasmodia and bacilli should not be co-ordinate and co-operative. I 
have seen such cases. Having met with cases which appeared 
to permit the two diagnoses, and mainly such as during and after 
a clear course of typhoid fever developed regular attacks of chills 
and fever, I have administered quinine for some time. Several times 
these attacks appeared to be quite grave, and were mostly obstinate. 

The paratyphoid fever described by Gwyn, Schottmiiller, and 
Meltzer, without Widal reaction, and with a bacillus more nearly 
related to the colon than the typhoid bacillus, offers no new thera- 
peutic indications. 

13 



I94 INFECTIOUS DISEASES 

5. Typhus. Relapsing Fever. Weil's Disease. 

The hygienic and therapeutical measures to be taken in (petechial) 
exanthematic typhus are in part like those of typhoid fever. Fresh 
air, hydrotherapy, plenty of water, some alcohol, as few antifebrile 
medicines as possible, and heart stimulants when indicated, com- 
prise the treatment. Convulsions are not rare, conjunctivitis, laryn- 
gitis, and capillary bronchitis frequent. But the duration of the 
illness is much shorter than that of typhoid, and the prognosis is 
better in the child than in the adult. As there are no intestinal 
symptoms, feeding need not be exclusively fluid during recovery. 

Relapsing fever permits of solid food in the intermissions. The 
spleen, when very large and sensitive, requires ice applications. Com- 
plications with eye or ear diseases have their own indications. Qui- 
nine appears to do very little. Indications should be met as they 
appear. 

Of Weil's disease (fever, large liver and spleen, icterus, nephritis, 
delirium, coma, erythema, labial herpes) even Baginsky has seen but 
a single case (" Lehrbuch," 5th ed., p. 214). 

6. Epidemic Cerebrospinal Meningitis. 
It is both endemic and contagious, and demands absolute isolation 
and exclusion of brothers and sisters from schools and public play- 
grounds, also rest both of mind and body from the very beginning 
and for weeks or months after recovery. Though the prognosis 
of those cases which do not terminate fatally in the first twenty-four 
hours, and in some of which not even a differential diagnosis can 
be made with certainty, be much better than in the different forms 
of cerebral meningitis, the long duration of the disease endangers 
the result. Noise and glaring light must be excluded, no muscular 
exertion permitted, the neck supported ; in bad cases of hyperesthesia 
the bedclothing should not be permitted to touch the body. Hot 
bathing, once or twice a day in the beginning, may be tried to advan- 
tage. Lumbar puncture, formerly used for diagnostic purposes only, 
may do good, but cannot have the same effect as when the exudatioxi 
is altogether serous. The urinary bladder may require emptying. 
Leeches applied to the painful spine will do some good in the very 
early stages ; an ice-bag, on which the neck must be made to rest 
comfortably, another one to the occiput, and a purgative dose of 
calomel ought to usher in the remedial treatment. Unless contra- 
indicated by great sensitiveness, mercurial ointment externally and 
potassium iodide internally are expected to do good. The latter is 



CEREBRO-SPINAL MENINGITIS 



195 



generally given in too small doses, and thus misses its effect; from 
three to five grammes (forty-five to eighty grains) daily, and more, 
are easily tolerated, and are required by a child of five years. It may 
be preceded by a purgative dose of calomel ; altogether, it is necessary 
to keep the bowels open. Much handling, however ( enemata) , is mostly 
contraindicated on account of the pain and convulsions caused thereby. 
Stimulants are contraindicated, certainly in the first period of the ill- 
ness. The diet of the acute stage should be milk, cereals, and fruit- 
juices. Bromides will quiet excessive restlessness (doses of from one 
to four grammes a day) ; there are, however, very few cases that are 
not greatly benefited by sufficient doses of opiates or chloral to insure 
comfort and sleep. Sinapisms should be applied for a few minutes 
at a time, and frequently repeated; in the later stages a vesicatory 
over the cervical part of the spine is indicated. I am not pleased 
with the effects of tincture of iodine or iodoform ointments. Salicylic 
acid and salicylates have been praised ; but I am afraid that the cases 
in which their good effects were observed were those of mistaken 
diagnoses ; for, indeed, rheumatism both of the muscles and the menin- 
ges has been taken for different forms — even the very gravest — of 
meningitis. The after-effects of the disease, particularly paralysis 
and contractures, are difficult to handle; their treatment does not 
call for any special measures dictated by the original disease. Deaf- 
ness originating in the labyrinth or in the acoustic nerve is liable 
to prove permanent, in spite of hydrotherapy, diaphoresis, and electro- 
therapy. Amblyopia from inflammation of the chiasma and the optic 
nerves gives a bad prognosis ; keratitis and panophthalmitis are 
serious. The actual cautery has been used extensively. In the acute 
stage of the disease it is useless or harmful ; in the chronic it has 
been known to do good, and may be applied regularly. 

The modern progress of our acquaintance with the etiology of 
infectious diseases adds to our preventive, not yet to our curative, 
powers. H. Jaeger (Zeitsch. f. Hyg. u. Infect., vol. xix. p. 351) 
asserts that sixty per cent, of all cases of cerebro-spinal meningitis 
are connected with or dependent on the pneumococcus (and diplo- 
coccus intracellularis?). This explains the frequent complication 
with pneumonia. Thus, the nasal secretion in which the diplococcus 
is of frequent occurrence requires particular attention. Indeed, as 
early as 1888 the Prussian government ordered the disinfection of 
linen — mainly handkerchiefs — from this point of view. For the same 
reason the violent aspiration of the naso-pharyngeal secretion, for the 
purpose of expectoration, may prove unfortunate for the individual 
and, secondarily, for the community. Weichselbaum, Heubner, and 



196 INFECTIOUS DISEASES 

Fiirbringer charge the meningococcus intracellularis with being the 
cause. This microbe may also penetrate into articulations and give 
rise to a sero-fibrinous exudation, which, like the cerebro-spinal, has 
a tendency to absorption and recovery, different from the termination 
of those forms of arthritis which depend on streptococci and staphy- 
lococci. 

7. Glandular Fever. 

Under the name of " glandular fever," Pfeiffer (1887), A. Seibert 
(1894), I. P. West (1896), and Dawson Williams (1897) described 
a complex of symptoms which is claimed as a well-characterized dis- 
ease sui generis. Patients were from seven months to thirteen years 
old (Dr. Seibert's case fourteen). Parotids not affected. West's 
ninety-six cases occurred in forty-three families within three years, 
none during the summers. Many of the families lived at a distance 
from one another, but exposure and contagion could be proven in 
the majority. Incubation mostly seven days (Williams's five to seven, 
also fifteen days, mostly seven). Williams also observed many cases 
in the same family. The disease begins with anorexia, malaise, some- 
times vomiting, some slight diarrhcea, after some days dysphagia. 
There is (Seibert) no pseudo-membrane in the throat, no pharyn- 
gitis ; in a few cases opisthotonos, which is explained by the swelling 
of the lymph-nodes. Fever moderate, in some cases temperature 
(Seibert) normal in the morning, 104 F. in the evening. Some 
abdominal pain, diarrhcea in milder cases, constipation in more 
severe ones. No sequelae and no second attacks in West's cases. 
The disease lasted up to six weeks, in West's cases sixteen days, 
in Williams's from four to twenty-seven, with an average of six- 
teen; one death in ninety-six cases (West), one in twenty-four 
(Seibert). The main symptoms were the swellings of lymph-nodes, 
rarely of one side, mostly of both, beginning, however, on the left 
side; the right side followed in a few days. The glandular swell- 
ings extend downward and forward from the angle of the jaw and 
can be felt distinctly and separated from one another (West). The 
number of these swellings varies from four described by West to 
many small hard nodes, distinctly palpable, mostly between the deep- 
seated muscles of the posterior half of the neck (Seibert). Pos- 
terior cervical, axillary, and inguinal lymph-nodes could be felt in 
seventy-five per cent., the mesenteric in thirty-seven cases. The 
liver was found enlarged in eighty-seven cases (by Williams in 
ninety per cent.), the spleen in fifty-three cases (by Williams in 
fifty per cent., by Seibert in none), the tracheo-bronchial glands in 



GLANDULAR FEVER. CATARRHAL FEVER. CHOLERA 197 

all of Williams's cases. There were no oedema, no suppuration, 
no permanent enlargement. In the discussion of the Pediatric Sec- 
tion of the New York Academy of Medicine, Koplik (who never 
saw a case in his many thousands of observations) suggested the 
possibility of an intestinal infection because of the fact that the local 
symptoms started on the left side. The reports regarding the exist- 
ence of an incubation and the occurrence of contagion cause me, for 
the present, to connect the affection here with infectious diseases of 
a special type. The treatment should be mostly symptomatic; the 
(streptococcus?) invasion seems to find its spontaneous termina- 
tion. But there may be a transmission to the nares and antra, also 
occasionally a latero-pharyngeal abscess. 

8. Catarrhal Fever. 

This is not the " ephemeral fever" of a feverish infant or child 
the cause of which has not been diagnosticated, nor the result of over- 
loaded stomach or of intestinal putrefaction, nor of cocci in the throat 
or nose, but of the reflex irritation depending on " cold," exposure 
to a cold temperature, or to a sudden change of temperature from hot 
to cold, particularly while the skin is perspiring. Sometimes a 
chill is noted in the beginning, or merely a high temperature, aching 
muscles, anorexia, headache, perspiration, and some catarrhal angina ; 
in other cases very slight elevation of temperature and little perspira- 
tion, but lassitude, sleepiness, and constipation. Labial herpes is apt 
to appear on the second or third day and a copious perspiration is fre- 
quently noticed on the fourth or fifth day, after which, with plenty of 
urates in the urine, improvement takes place. To speak of a gastric, 
hepatic, or cerebral variety, in order to denote the most prominent 
symptoms, is superfluous. The treatment consists in rest in bed, at a 
temperature of from 65 to 75 F., plenty of water (preferably hot), 
or of hot lemonade for older children, a purgative (ol. ricini), tinct. 
aconiti in from one-quarter- to one-half-drop doses every hour or 
every two hours, liquor ammonii acetatis from three to ten drops 
every two hours in hot water, and, if there be much headache and 
a high temperature, phenacetin in from one-half- to one-grain (0.03 
to 0.06) doses from time to time. 

9. Asiatic Cholera. 

It is almost always fatal in the infant, and little less so up to the 
fifth or sixth year. Its diagnosis is, during an epidemic, secured 
by the presence of the characteristic diarrhoea and vomiting, with 
cold extremities, cyanosis, algidity, and the absence of pulse and 



198 INFECTIOUS DISEASES 

of urine ; lastly and positively, by the presence of the comma bacillus 
in the fecal discharges. The differential diagnosis should be made 
from arsenic and tartar-emetic poisoning, also from very acute nephri- 
tis. The latter may exhibit the same copious rushing " rice-water" 
discharges of serum with masses of epithelium. 

As the disease is identical with that in the adult, so the general 
features of the treatment are the same. Preventive immunization 
has been practised, after many previous attempts made in vain, by 
Haffkin. If his favorable results obtained in the East Indies are 
confirmed, and the Mecca pilgrimages closely watched, the world will 
be threatened with one less danger. During the prevalence of an epi- 
demic no child should be permitted to suffer either from diarrhoea or 
from vomiting. Wet or soiled linen must be disinfected and boiled 
immediately. Whatever is to pass beyond the lips, mouth-wash or 
food or drink, should be boiled. Invalid or dyspeptic children should 
be sent away, and the schools closely watched for the slightest attack 
of loose bowels. A child suspected of cholera is to be kept in bed, 
with small hourly doses (five or ten milligrammes) of calomel, which 
ought to be continued until the faeces show the characteristic color. 
Creosote may be given in water, in moderate doses only, for the 
kidneys are apt to suffer ; salol in doses of from five to fifty centi- 
grammes every few hours. Diluted hydrochloric acid ( I to 500) as 
a drink after the administration of calomel has been stopped. The 
extremities should be kept warm, the abdomen, if hot and tender, 
covered with cold applications, which should be changed when they 
become warm, and stimulants given freely (alcohol, coffee, caffeine, 
strychnine, camphor, tincture of musk), subcutaneously if, or be- 
cause, the stomach retains nothing. Warm bathing with friction 
while in the bath; the bath water should be boiled before being used, 
to destroy the comma bacillus, if not its toxins. No internal dia- 
phoretics, and absolutely no pilocarpine subcutaneously. For the 
heart is too feeble ; even when the condition appears to improve, 
sudden relapses and collapse may ensue. The enteroclysis of Can- 
tani (the irrigation to be carried up as far into the bowels as pos- 
sible) is made with a solution of three or five parts of tannic acid 
in a thousand of warm, or hot, water. The action of the heart may 
be re-established by subcutaneous salt-water infusions. For these 
Cantani's original prescription contained four parts of sodium chlo- 
ride and three of sodium bicarbonate in one thousand of water. 
Opium is badly tolerated in all stages. High temperatures and de- 
lirium demand cold to the head ; pneumonia, parotitis, nephritis, and 
other complications furnish their own indications. 



DYSENTERY 199 

10. Dysentery. 

It is communicated from person to person, but by fecal discharges 
only; by the use of the same chamber, for instance. Indeed, all the 
bacillary diseases of the intestinal tract may enter through the anus. 
Privies and sewers are sources of dysentery, as of typhoid fever; but 
a more frequent cause is the drinking of water infected by sewage, 
which need not always contain specific microbes. Their toxins suffice. 
Amoebae, which were believed to be very rare, and the cause of a spe- 
cific variety, are probably concomitants of most cases. The catarrhal, 
the follicular, and the diphtheritic varieties may run their courses 
separately; in many instances, however, the first will only be the 
initial stage of the more serious forms. The treatment is not, for 
the present, influenced by the species of microbes causing or com- 
plicating the malady, bacterium dysenteriae, diphtherias, coli, or 
amoebae. 

To prevent contagion, a patient with dysentery should be isolated. 
During the heat of the summer children should be protected against 
colds (the systematic external use of cold water is, as always, the 
best prophylactic) and unripe fruit. 

The sufferings from dysentery are so intense, and the dangers from 
its acute (fever, convulsions, exhaustion) or chronic (scurvy, noma, 
nephritis, paralysis, neuritis, diseases of joints, abscess of the liver) 
state so threatening, that active measures should be taken at once. 
A brisk purgative ought to precede every other treatment. Castor 
oil in sufficient quantities, or calomel — according to age — in doses 
of from one to eight grains (0.05 to 0.5), will have a favorable effect, 
the latter acting both as a laxative and a disinfectant. 

The food should be liquid, milk and strained farinaceous decoc- 
tions the exclusive diet for the first acute stage. It is on the general 
condition of the patient that the administration of other articles of 
food, such as jellies without sugar, beef- or mutton-broth with fari- 
naceous decoctions, Qgg albumin, or alcoholic and medicinal stimu- 
lants (either general or cardiac), will depend in the course of the 
disease. 

Great sensitiveness of the left hypogastric region and local heat 
will be alleviated by the application of ice. Very young infants, how- 
ever, bear ice but a short time, whether applied to head or abdomen. 
I advise to watch the effect of the application of either the ice-bag 
or the ice-cold cloth. Now and then, even in adults, we meet with 
an individual intolerance of cold which must be respected. Indeed, 
quite often warm applications of either water or poultices prove more 



200 INFECTIOUS DISEASES 

efficient in regard to the two indications, which consist in alleviating 
irritation and reducing temperature. 

Bismuth subgallate and subcarbonate not only cover and protect 
the mucous membrane, but have also a decided antifermentative 
effect. Thus bismuth is surely indicated in irritated conditions of 
the mucous membrane ; it seldom fails when given in sufficient doses. 
There is no harm in sometimes giving it in such doses that part of 
the introduced material will pass through the entire length of the 
intestinal tract without undergoing decomposition. As its taste is 
not disagreeable, it may be given together with tannin (gallic acid 
is better) and opium; the daily dose ought not to be less than one 
drachm or a drachm and a half (4.0 to 6.0). At the same time the 
passages ought to be examined as to their reaction. Abundant acid, 
so frequently found in the slightest intestinal anomalies, requires the 
additional administration of alkalies. Boiled milk should be mixed 
with equal parts of lime-water. In most cases carbonate of lime is 
preferable to either magnesium or sodium carbonate or bicarbonate, 
the salts of both of which are apt to increase diarrhoea. Sometimes, 
particularly when the stomach can be relied upon, sodium salicylate 
may be added to the internal treatment. Besides the favorable effect 
of the sodium on the intestinal tract, the salicylic acid may prove 
beneficial both by its antifebrile and disinfectant action. Salol, about 
one or two grains (0.05 or 0.15), or resorcin, one-quarter or one 
grain (0.015 or 0.06), given every two hours, may take its place. 
The latter is better tolerated than the former, but salol has a better 
chance to reach the lower part of the intestine. 

Opium and its alkaloids are invaluable in the treatment of intes- 
tinal ulcerations. The objections to their use are decidedly exag- 
gerated. Such accidents as have been reported in isolated cases as 
resulting from the administration of opium are to be attributed to 
the fact that the dose was either absolutely or relatively too large 
compared with the idiosyncrasy of the patient. Dysentery both re- 
quires and tolerates larger doses of opium than an average diarrhoea, 
no matter whether the latter be the result of catarrh or ulceration 
of the small intestine or the caecum or the upper part of the colon. 
In this respect dysentery stands almost abreast with peritonitis. The 
main indications are to relieve pain, reduce peristalsis, and diminish 
the copious serous secretion ; no other remedy fulfils all of them so 
well. For these purposes it ought to be given internally ; for enemata 
containing opium may act favorably, but the more intense the tenes- 
mus and the greater the hyperemia or the more extensive the ulcera- 
tion the less reliance can be placed on their effect, and the amount 



DYSENTERY 201 

of the opiate thus brought into real action cannot be estimated. 
Among all the opiates I prefer a tincture, or the wine, or opium 
in substance, or Dover's powder; rarely have I injected morphine 
under the skin. The effect of the drug is easily watched and con- 
trolled by commencing with moderate doses, not repeating them too 
often, and being guided by the effect obtained. If opium is to be dis- 
carded, opium with hyoscyamus, or with belladonna, or hyoscyamus 
or belladonna alone, may take its place temporarily. Severe tenesmus 
may require the painting of the protruding part with Magendie's 
solution. 

Astringents may be given either in combination with opium or 
separately. They are expected to pass wholly or partly through the 
entire length of the intestinal canal, thus coming into contact with 
the inflamed and ulcerous mucous membrane. Among those eligible 
are (tannin) gallic acid and vegetables containing the same (ratanhia, 
catechu), besides lead subacetate, silver nitrate, and pernitrate of 
iron. 

The daily dose of gallic acid, when it is to be taken for a long 
time in succession, is from five to fifteen grains (0.3 to 1.0), lead 
subacetate one to five grains (0.05 to 0.3), silver nitrate one-fourth 
to one-half grain (0.015 to 0.03). The latter ought not to be given 
more than a week or two in succession, for fear of argyria, two 
cases of which occurred in my own practice, and of my own making, 
many years ago. All of these medicines, except gallic acid, are best 
taken, if possible, in the form of pills. They appear to be better 
tolerated, and are certainly more effective. Silver nitrate in solu- 
tion (distilled water) demands a bottle of neutral color and admin- 
istration from a glass or china vessel. 

Another antiseptic which I have frequently administered inter- 
nally in every description of intestinal ulcerations, in both the acute 
and the chronic forms, is naphtalin. For its doses and the methods 
of its administration, and some account of its effect on intestinal 
ulceration in general, I refer to the article on typhoid fever. We 
expect a great deal from such topical medication, and it appears 
that it will be one of the great aids in all infectious diseases whose 
principal localization is in the intestine, as, for instance, Asiatic 
cholera. 

Adults will take from fifteen to seventy-five grains (1.0 to 5.0) 
daily, in powders, capsules, or mucilage. Children bear, as a rule, 
according to their ages, from one-half of a grain to two or three 
grains (0.03 to 0.2), every two or three hours, in some mucilaginous 
substance. Some do not bear it well, but when such is the case the 



202 INFECTIOUS DISEASES 

stomach will give warning at once. Its odor, it is true, is objection- 
able. 

The temperature will rarely be so high as to require antipyretic 
medication. Frequent enemata will often reduce it effectively. Very 
young infants may require an occasional dose of antipyrin or phe- 
nacetin when the heat threatens either the nervous system or the 
normal structure of the tissues of the body. A warm bath will often 
do better than either. 

Consecutive paralysis requires a mild galvanic current in the 
beginning. The daily application both to the spinal cord and the 
extremities need not exceed ten minutes; the electrodes should be 
large, and the current reversed after five minutes. After a few weeks 
the interrupted current may be added the same length of time, but 
it should be applied to the paralyzed muscles only. Together with 
the latter, strychnine or (and) phosphorus may be used, in daily doses 
of one-thirtieth of a grain (0.002), in the case of a child of four 
or five years ; the former is more effective when used subcutane- 
ously. 

The local treatment of chronic dysenteric ulcerations requires 
the use of enemata. Their indications vary. They are to evacuate 
the bowels, or to reduce the irritability of the diseased intestine, or 
to accomplish a local cure. These indications cannot be fulfilled sepa- 
rately; sometimes two, sometimes all three, may be met at the same 
time. The nature and quantity and the temperature of the liquid to 
be injected depend in part on the end aimed at, in part on the irrita- 
bility of the individual intestine. Sometimes the bowel objects to the 
introduction of small amounts ; sometimes, however, large quantities 
are tolerated very easily indeed. To introduce small amounts, the 
selection of the syringe is a matter of indifference, provided the 
liquid enters the bowel gently and without pain. To inject large 
quantities, undue pressure and local irritation should be avoided. 
Therefore the fountain syringe alone will answer; it ought to hang 
but a trifle above the level of the anus, — say from six to twenty 
inches. The temperature of the liquid is not always a matter of 
great importance. Some recommend the injections to be ice-cold; 
some, however, tepid ; both are frequently recommended as panaceas. 
But the practitioner will soon ascertain that some bear and require 
the one, some the other ; some, indeed, very hot ones. 

In my experience, for the large majority of patients suffering 
from either acute or chronic dysentery, tepid injections answer best. 
Not rarely the intestine is in such a condition of irritation that even 
small quantities of a very cold fluid are expelled at once. And again, 



DYSENTERY 



203 



there are cases in which enormous amounts of either cold or warm 
water are readily received. To accomplish the purpose of evacu- 
ating the bowel, plain water will often suffice, but three-fourths-of- 
one-per-cent. solutions of salt in water will usually prove more 
acceptable. Additions of potassium bitartrate or castor oil have 
proved so uncomfortable in my cases that I discarded them long ago. 
However, when the secretion of mucus on the rectal and intestinal 
mucous membranes was very large, one- or two-per-cent. solutions 
of sodium bicarbonate answered very well indeed. For the purpose 
of clearing the intestines, either of faeces or the morbid products, a 
single enema is insufficient. It ought to be repeated several times 
daily. When much mucus is secreted and tenesmus intense, it may 
be applied after every spontaneous evacuation. In many cases the 
substitution of flaxseed tea or mucilage of gum acacia will prove 
advantageous. I have had to continue them for weeks for both their 
evacuating and alleviating effect. When, however, the latter alone 
is aimed at, — that is, when tenesmus is to be relieved, — small quan- 
tities will usually suffice. An ounce or two of thin mucilage, or 
starch-water, or flaxseed tea, with tincture of opium or, better, ex- 
tract of opium, proves very comforting. Glycerin in water has been 
recommended for the same purpose. The former alone, or but slightly 
diluted, irritates, nay, cauterizes. It will require close judgment and 
individual experience to ascertain the degree of dilution, if it be used 
at all. In these cases I avoid it. 

When a local curative effect is aimed at, injections of small quan- 
tities are sometimes insufficient. As the local lesions are often exten- 
sive, the amount to be injected must be pretty large. Astringents are 
almost always required. Zinc or aluminum sulphate, lead subace- 
tate, silver nitrate, tannin, potassium chlorate, ergotin, salicylic and 
carbolic acids, and creosote have been recommended. Of the more 
common astringents I prefer alumina or tannin in less than one-per- 
cent, solutions. Salicylic acid resulted more frequently in pain than 
in benefit. Carbolic acid, in solutions of one-half of one per cent., 
has proved very beneficial, but I have learned long ago to be very 
careful in regard to its administration because of its detrimental 
effects, particularly on the kidneys of very young patients. 

Injections of silver nitrate may prove very useful in cases not 
quite acute. Before the solutions of a quarter of one per cent, or 
of one or two per cent, are injected, the intestine ought to be washed 
out with warm water (without salt) or with a two- or three-per-cent. 
boracic acid solution. After the injection has been made, it ought 
to be neutralized with a solution of sodium chloride ; it is still 



204 INFECTIOUS DISEASES 

better to wash the anus and the portion of the rectum within easy 
reach with that solution before the medicinal injection is made. For 
even the mildest solutions, when acting- on the sore sphincters, are 
liable to give rise to intense tenesmus when no such care has been 
taken. 

When the ulcerations are few, or in the lower portion of the 
bowels only, small quantities suffice; but extensive lesions require 
large injections, the patient being on his side or in the knee-elbow 
position. For older children the nozzle of the fountain syringe should 
be lengthened by attaching to it an elastic catheter, which is intro- 
duced as high up as possible, after the same plan that nutrient enemata 
are to be given. In a- number of cases, both mild and severe, in which 
neither the usual astringents nor silver nitrate appeared to answer, 
I have been very successful these thirty years, when resorting to 
injections of bismuth subcarbonate. The drug is mixed with six 
or twenty times its amount of water ; of this mixture from one to 
three ounces (30.0 to 100.0) are injected into the bowel, which has 
been washed out previously, twice or three times daily. The result 
is satisfactory, though a large portion of the injected mixture be soon 
expelled. 

Suppositories containing the above substances may prove bene- 
ficial ; but in order not to irritate they must be so soft as to melt 
readily. They may always contain some opium ; but its admixture 
is not always sufficient to relieve the irritability of the rectum. Indeed, 
to accomplish this end opium must at least begin to liquefy and to 
be absorbed, and absorption cannot be relied upon except where a part, 
at least, of the mucous surface is in a fair state of integrity. When 
no suppository is tolerated, and the administration of an opiate to 
the intestine is indicated, painting with Magendie's solution or the 
injection of a small quantity of olive oil with tincture of opium may 
be tried. The local application of cocaine relieves pain, but the 
drug is readily absorbed, and great caution should be used in its 
administration because of its poisonous effects. 

11. Scarlatina. 
Preventive measures of the strictest nature are indicated in regard 
to no disease more than to scarlatina. Its mortality is very great, 
in some epidemics even excessive ; and when the child survives, there 
may be a large number of sequelae which either terminate fatally 
or in persistent injury to health and in the curtailing of the enjoy- 
ment or usefulness of life. Among these are cardiac diseases, glan- 
dular affections, suppurative otitis, and nephritis. The first attack 



SCARLATINA 205 

of the latter is not limited to the second or third week, when, it is 
true, it is mostly met with; for I have seen it appear on the thirty- 
seventh and on the fifty-second day of the disease. Baumler reports 
the case of a child with hemorrhagic nephritis which started as late 
as the forty-fourth day of scarlatina. 

There is another momentous indication for strict prevention. The 
liability to attack is by no means so great as, for instance, in measles. 
It is but rarely that any of the young inmates of a house escape 
contagion when measles has attacked one of them. The virus of 
scarlatina, however, is less catching. Infants of less than a year 
suffer but seldom, though very severely when taken. The vast 
majority of those affected, however, are less than five years old. 
After that period susceptibility becomes less from year to year ; so 
that, indeed, a child that has been protected against scarlatina during 
its first half-dozen years attains a certain degree of immunity for the 
future. 

The efficacy of the virus is so persistent, and clings so long to 
clothing, bedding, and furniture, that it can be carried and trans- 
mitted long distances by persons, towels, toys, letters, and even do- 
mestic animals and articles of food, principally milk. It is trans- 
ferable through the whole duration of the disease, from the incubation 
to the disappearance of the very last trace of desquamation, and 
perhaps later; even before the appearance of the eruption. The in- 
cubation of scarlatina may last but a few hours, like that of diphtheria 
and erysipelas, or as long as nine days ; in this it differs greatly from 
measles, variola, and varicella. The last symptoms may not disappear 
until long after the fortieth day, which, it is true, is the average 
termination. The fine desquamation of the second week may have 
terminated entirely, but the gross peeling, particularly of the hands 
and feet, extends frequently to the end of the seventh or eighth week. 
It carries contagion as well as the desquamation of the former 
weeks, or as the breath of the patient, or his expectoration in the 
earlier periods. So slow is sometimes the process of elimination that 
Spottiswood Cameron asserts that the end of the disease is seldom 
reached before the eighth week, and not always in the thirteenth. 
Whether the urine or the alvine dejections of the patient can spread 
the disease is not quite certain ; but so long as there is an uncertainty 
they ought to be treated as dangerous elements and disinfected and 
removed. 

Sore surfaces appear to admit the poison. Scarlatina will enter 
through the integuments denuded by eczema. I believe that I lost, 
many years ago, two patients because I operated upon them during 



206 INFECTIOUS DISEASES 

the prevalence of an epidemic of scarlatina. A child of four years, 
on whom I resected the head of a femur, was taken with the eruption 
on the fourth day and died. Another one was stricken down thirty- 
six hours after the resection of a tonsil. In both cases I had reason 
to believe that I opened an inroad to the poison. Indeed, catarrhal 
or otherwise sore tonsils — even healthy tonsils with the normal in- 
terruptions of their epithelial covering — are very likely to furnish a 
means of invasion. Several times I observed scarlatina a few days 
after tracheotomy. 

Dispensaries and schools are the hotbeds of scarlatina. A single 
case waiting in the anteroom of a public charity until it is seen and 
diagnosticated may destroy a dozen innocents while craving the bless- 
ings of public beneficence. Schools ought to be closed during an 
epidemic as soon as a few cases have appeared. No child coming 
from a house with scarlatina must be admitted. Such as have been 
removed from the dangerous neighborhood and not exposed since 
may, after thorough disinfection of the clothing worn during the 
time of exposure, be allowed to return after an interval of ten 
days. 

The daily school inspection of the New York Health Department, 
organized a few years ago, after the profession had urged its necessity 
from time to time these thirty years, cannot fail to be very beneficent, 
and is among the best methods to improve public health employed 
by the health department of the city. There cannot be a doubt as 
to its example being imitated in other places. The " inspectors are 
to carefully examine each pupil that has been set apart from the other 
pupils by the teachers of the school, and cause to be excluded from 
schools all those affected with, or showing symptoms of, any con- 
tagious disease, more especially the following: measles, diphtheria, 
scarlet fever, croup, whooping-cough, mumps, contagious eye diseases, 
parasitic diseases of the head and body, or any illness which, in their 
judgment, shall require the pupil to be excluded from school." 

The inunction of the patient with pork, vaseline, and similar sub- 
stances adds to the safety of the attendants by preventing the carry- 
ing into the air of the eliminated particles of epidermis. Soaping 
and bathing contribute to the same end, but are not perfectly reliable 
safeguards because the virus penetrates the whole skin down to the 
rete Malpighii. 

The sick and their attendants must be strictly isolated; during 
the winter, when the warm air rises and carries contagion with it 
to the upper part of the house, in the highest story. Whoever enters 
the sick-room — friend, nurse, or physician — ought to wear special 



SCARLATINA PREVENTION 207 

clothing while inside, or at least a linen or India-rubber cover. The 
physician should disinfect, his hands after leaving the patient. In 
the room the air ought to be changed often. Draught can be avoided 
by means of screens. No dry linen or clothing must leave the room. 
It should be soaked in water or, better still, in a disinfectant fluid 
before it is carried off, and boiled in soap and water immediately after 
arriving in the laundry. The same rules which hold good in the 
cases of infectious and contagious diseases in general, and those which 
refer to the disinfection of the room and furniture and public vehicles 
which may have been used, must be obeyed to the letter. No room, 
in fair weather, will afford the same safety as a tent would, and in 
no disease, with the exception of variola and diphtheria, is the erec- 
tion and maintenance of special hospitals more needed than in scar- 
latina. 

In connection with the question of prevention of contagious dis- 
eases, scarlatina and others, I cannot render better service than by 
giving the greatest possible publicity to the directions of the New 
York Health Department. They contain all that is known and all 
that ought to be done, in city or country, to prevent scarlet fever, 
diphtheria, and measles in the present state of society and of our 
knowledge. 

" Diphtheria, Scarlet Fever, Measles. 

" These diseases are very contagious. Diphtheria is usually trans- 
mitted from the sick to the well by the moist or dry discharges from 
the nose and throat of the sick person. Scarlet fever and measles 
are transmitted by the discharges from the nose and throat and also 
by the scales thrown off from the surface of the skin. These dis- 
charges and scales contain the minute germs that cause these dis- 
eases. The importance, therefore, of their proper disinfection can 
be at once understood. 

" Directions to prevent other Cases of Diphtheria, Scarlet 
Fever, and Measles occurring in a Family where One Case 
exists. 

" 1. If possible, one attendant should take the entire care of the 
sick person, and no one else besides the physician should be allowed 
to enter the sick-room. The attendant should have no communication 
with the rest of the family. The members of the family should not 
receive or make visits during the illness. 

"2. The discharges from the nose and mouth must be received 
on handkerchiefs or cloths, which should be at once immersed in a 



208 INFECTIOUS DISEASES 

carbolic solution (made by dissolving six ounces of pure carbolic 
acid in one gallon of hot water, which may be diluted with an equal 
quantity of water). All handkerchiefs, cloths, towels, napkins, bed- 
linen, personal clothing, night clothes, etc., that have come in contact 
in any way with the sick person, after use should be immediately 
immersed without removal from the room in the above solution. 
These should be soaked for two or three hours and then boiled in 
water or soapsuds for one hour. 

" 3. In diphtheria and scarlet fever great care should be taken, in 
making applications to the throat or nose, that the discharges from 
them in the act of coughing are not thrown into the face or on the 
clothing of the person making the applications, as in this way the dis- 
ease is likely to be caught. 

" 4. The hands of the attendant should always be thoroughly 
disinfected by washing in the carbolic solution, and then in soapsuds, 
after making applications to the throat or nose, and before eating. 

" 5. Surfaces of any kind soiled by the discharges should be 
immediately flooded with the carbolic solution. 

" 6. Plates, cups, glasses, knives, forks, spoons, etc., used by the 
sick person for eating and drinking must be kept for his especial use, 
and under no circumstances removed from the room or mixed with 
similar utensils used by others, but must be washed in the room in the 
carbolic solution and then in hot soapsuds. After use the soapsuds 
should be thrown in the water-closet, and the vessel which contained 
it should be washed in the carbolic solution. 

" 7. The room occupied by the sick person should be thoroughly 
aired several times daily, and swept frequently, after scattering wet 
newspapers, sawdust, or tea-leaves on the floor to prevent the dust 
from rising. After sweeping, the dust upon the wood-work and fur- 
niture should be removed with damp cloths. The sweepings should 
be burned and the cloths soaked in the carbolic solution. In cold 
weather, the sick person should be protected from draughts of air 
by a sheet or blanket thrown over his head while the room is being 
aired. 

" 8. When the contagious nature of the disease is recognized 
within a short time after the beginning of the illness, after the approval 
of the Health Department Inspector, it is advised that all articles of 
furniture not necessary for immediate use in the care of the sick 
person, especially upholstered furniture, carpets, and curtains, should 
be removed from the sick-room. 

" 9. In scarlet fever and measles, when the patient is beginning 
to recover and the skin is peeling off, the body should be washed once 



SCARLATINA. DISINFECTION 



209 



daily in warm soapsuds, and afterwards anointed with oil or vaseline. 
This should be continued until all roughness of the skin has dis- 
appeared. 

" 10. When the patient has recovered from any one of these 
diseases, the entire body should be bathed and the hair washed with 
hot soapsuds, and the patient should be dressed in clean clothes (which 
have not been in the room during the sickness) and removed from the 
room. Then the Health Department should be immediately notified, 
and disinfectors will be sent to disinfect the room, bedding, clothing, 
etc., and under no conditions should it be again entered or occupied 
until it has been thoroughly disinfected. Nothing used in the room 
during the sickness should be removed until this has been done. 

"11. The attendant and any one who has assisted in caring for 
the sick person should also take a bath, wash the hair, and put on 
clean clothes, before mingling with the family or other people, after 
the recovery of the patient. The clothes worn in the sick-room should 
be left there, to be disinfected with the room and its contents by the 
Health Department. 

" Methods of Disinfection. 

" 1. Hands and Person. — Standard Solution No. 1 should be 
diluted with an equal amount of water. Hands soiled in caring for 
persons suffering from contagious diseases, or soiled portions of the 
patient's person, should be immediately and thoroughly washed in this 
solution, and then washed with soap and water. The nails should be 
kept perfectly clean and the hands should always be carefully disin- 
fected before eating. 

" 2. Soiled Clothing, Towels, Napkins, Bedding, etc., should be 
immediately immersed in Standard Solution No. 1, and soaked for 
twelve hours, being occasionally moved about in the fluid so as to 
bring the disinfectant in contact with all parts. They should then be 
wrung out and boiled in soapsuds for one hour. Articles, such as 
beds, etc., that cannot be washed should be burned. 

" 3. Food and Drink. — Food thoroughly cooked and drinks that 
have been boiled are free from disease germs. In presence of an epi- 
demic of cholera or typhoid fever, milk and the water used for 
drinking, cooking, washing dishes, etc., should be boiled just before 
using, and all persons should avoid eating fruit, fresh vegetables, 
and ice. Ice may, however, be used when ordered for the sick by a 
physician. 

" 4. Discharges of all kinds from patients suffering from con- 
tagious diseases should be received into earthen vessels containing 

14 



210 INFECTIOUS DISEASES 

Standard Solution No. i or 3. Special care should be observed to 
disinfect at once the vomited matter and the intestinal discharges 
from cholera patients, as these alone contain the dangerous germs. 
The volume of the disinfecting- solution used should be at least four 
times as great as that of the discharge. After standing for at least 
one hour in the disinfecting solution, these discharges may be thrown 
into the water-closet. Bedding or clothing soiled by the discharges 
must be at once placed in Solution No. 1, and the hands of the attend- 
ants disinfected, as described above. 

" 5. Closets, Sinks, etc. — Each time the closet is used for infected 
material, at least one quart of Solution No. 1 should be poured into the 
emptied pan and allowed to remain there. All discharges should be 
disinfected before being thrown into the closet. Sinks should be 
flushed at least once daily with the same solution. 

" 6. Dishes, Spoons, etc., used by the patient should be kept for 
his exclusive use, should not be removed from the room, but should 
be washed there, first in Solution No. 1, and then boiled in strong 
soapsuds. These washing-fluids should afterwards be thrown into 
the water-closet. The remains of meals should be thrown into 
a vessel containing milk of lime. The contents of the vessel, after 
standing half an hour or more, should be thrown into the water- 
closet. 

" 7. Soiled Wood-work, Floors, Plain Furniture, etc., should be 
thoroughly washed with Solution No. 2. Upholstered furniture, cur- 
tains, or carpets which have been soiled by the discharges should be 
referred to the Health Department for disinfection or destruction. 

" It is important to remember that an abundance of fresh air, 
sunlight, and absolute cleanliness not only help protect the attendant 
from infection, but also aid in the recovery of the sick. 

" Note. — The cost of the carbolic solution is much greater than 
that of the other solutions, but generally is to be much preferred. 
When the cost is an important element, the bichloride solution may be 
substituted for all purposes for which the carbolic is recommended, 
excepting for the disinfection of discharges, eating utensils, or articles 
made of metal, and of clothing, bedding, etc., which is very much 
soiled. Its poisonous character, except for external use, must be kept 
constantly in mind. 

" Disinfection and Disinfectants. 
" The contagious diseases are caused by minute living germs. 
The object of disinfection is to destroy these. In order that as few 
articles as possible shall be exposed to infection by the disease germs, 



SCARLATINA. DISINFECTION 21 1 

at the very beginning of the illness all unnecessary furniture (espe- 
cially upholstered furniture and curtains), and other unnecessary 
articles, should be removed from the sick-room. 

" The following are the best-known disinfectants : 

" I. Heat. — Continued high temperatures destroy all forms of 
life. Boiling for at least one-half hour will destroy all disease germs. 

" 2. Carbolic Acid. — Standard Solution No. i is composed of 
six ounces of carbolic acid, dissolved in one gallon of hot water. This 
makes approximately a five-per-cent. solution of carbolic acid. The 
commercial colored impure carbolic acid will not answer for this 
purpose. Great care must be taken that the pure acid does not come 
in contact with the skin. When practicable, the carbolic solution 
should be used as hot as possible. 

" 3. Corrosive Sublimate (bichloride of mercury). — Standard 
Solution No. 2 is composed of sixty grains pulverized corrosive subli- 
mate and sixty grains of chloride of ammonia, dissolved in one gallon 
of water. This solution must be kept in glass, earthen, or wooden 
vessels (not in metal vessels). 

" The above solutions are very poisonous when taken by mouth, 
but are harmless when used externally. 

" 4. Milk of Lime. — Standard Solution No. 3 is made by mixing 
one quart of dry freshly slaked lime with five quarts of water. Lime 
is slaked by pouring a small quantity of water on a lump of quick-lime. 
The lime becomes hot, crumbles, and as the slaking is completed a 
white dry powder results. The powder is used to make Solution 
No. 3. Air-slaked lime has no value as a disinfectant. 

" The proprietary disinfectants, often widely advertised, and 
whose composition is kept secret, are relatively expensive and often 
unreliable and inefficient. It is important to remember that substances 
which destroy bad odors are not necessarily disinfectants." 

The medicinal treatment of mild cases may be expectant. Cool- 
ing drinks — ten or twelve drops of dilute hydrochloric acid in a goblet 
of water — will often suffice. The food must be liquid, or at most 
semi-solid ; in the first week milk and farinacea. Constipation during 
the first period is relieved by a dose of calomel or a vegetable aperi- 
ent. Diarrhoea, particularly in the later stages, requires bismuth, 
opium, perhaps astringents, such as lead, and at all events antifer- 
mentatives, such as resorcin, salol, or naphtalin; the mild form of 
stomatitis and pharyngitis, half a grain or a grain of potassium 
chlorate in a teaspoonful of water every hour or two hours. Larger 
children should be taught how to gargle at regular intervals ; but the 
posterior wall of the fauces is reached better by frequent drinking 



212 INFECTIOUS DISEASES 

of ever so small quantities of water, or of water with a few drops 
of dilute hydrochloric acid, and by nasal irrigations. There should be 
no waiting for glandular swelling before the nose and the pharynx 
are attended to. The carbolic acid injections of Heubner and those 
of chlorine-water of Dr. A. Seibert into the tissue of the tonsils 
have not received the approval of the profession to any great extent. 
The throat complications of scarlatina should be attended to in time, 
either when caused or attended by streptococci or Klebs-Loffler 
bacilli. The frequency of the latter varies according to localities, sea- 
sons, and epidemics. Some observers claim them in fifteen per cent, 
of all cases of scarlatina. Ranke found pseudo-membranes in sixty- 
five per cent, of a season's cases at the Munich Children's Hos- 
pital. In 53.7 per cent, of mild or severe (laryngeal) cases he met 
with the diphtheria bacillus, in 38.8 with streptococci. The former 
were also observed in most of those cases in which the pseudo-mem- 
branous complication arose in the later stages of the disease. That 
is why he recommends the use of the diphtheria antitoxin in doubtful 
cases also. This and the important subject of general and local treat- 
ment of pseudo-membranous affections will be discussed in the article 
on diphtheria. In most cases (there are exceptions to that rule) when 
they are first observed on the fourth or fifth day of scarlatina they are 
seldom alarming ; when on the first day, or previous to the scarlat- 
inous eruption, they are quite ominous. In such instances they are 
often accompanied by rapid glandular swelling and serious symp- 
toms of sepsis. Applications of ice to the swollen neck will often 
keep the tumefaction within certain limits. When gangrenous degen- 
eration of the glands cannot be prevented, and local suppuration occurs 
in the centre, deep incisions and the local use of carbolic acid are 
required in the same manner in which the same affection is dealt with 
in diphtheric diseases generally. In milder cases, two applications 
daily of one part of iodoform in eight or twelve of flexible collodion 
have a good effect. Even they are mostly not wanted; cool appli- 
cations will suffice. Occasional retropharyngeal abscesses require 
incisions. 

High temperatures do not demand very active treatment unless 
they result in functional or organic changes of the heart or brain. So 
long as these two organs perform their duties normally the tempera- 
tures may be let alone. A very frequent and feeble pulse with a high 
temperature indicates, besides a cardiac tonic, quinine, rubbing with 
cool water or water and alcohol, cold applications to the heart, or a 
warm bath. A cold bath is not borne well ; in urgent cases a cold 
pack may do good. A feeble and arrhythmic pulse requires the very 



SCARLATINA. RHEUMATISM 213 

strongest stimulants. Phenacetin and antipyrin are not to be recom- 
mended in these conditions. Delirium and somnolence, also convul- 
sions, may be the results of high temperatures, and, particularly when 
the whole body, feet included, is hot, require the same treatment. 
Antipyrin, however, I have never seen to reduce the temperature in 
congestive or inflammatory conditions of the brain. The latter may 
be the direct result of the infection, but also, at a somewhat later 
period, of rheumatism. In either case the treatment does not materi- 
ally differ from what it would be under ordinary circumstances. The 
latter form requires salicylates, the application of ice to the head, 
counter-irritants to the feet (sinapisms) and intestines (calomel), 
and in rare cases leeches to the septum narium or to the mastoid 
processes. The vital indication proceeding from the condition of 
the brain is here of the greatest importance. 

When the same symptoms set in with or without a high rectal 
temperature and cold extremities, a mottled skin, and a cyanotic hue, 
the large amount of the toxin which has invaded the system demands 
strong stimulants, — ammonia, musk, and camphor. They act better 
than alcohol. To their internal administration may be added camphor 
dissolved in sweet almond oil, and sparteine sulphate in water, sub- 
cutaneously, in free and frequent doses. These toxic symptoms while 
the temperature is low bear opiates (morphine, one-fiftieth or one- 
twentieth of a grain, one to three milligrammes), in repeated doses, 
quite well. Universal heat requires tepid bathing, with cold affusions 
over, or applications to, the head ; a cool surface, with cold extremities 
and frequent and filiform pulse, hot bathing and powerful friction, and 
hot enemata, with stimulants. 

Vomiting before and with the eruption is a frequent symptom. 
When moderate, it may be let alone ; no food must be given for a 
number of hours, ice-water in teaspoon doses, or an ice pill, every five 
or fifteen minutes. When quite severe and exhausting, small doses of 
an opiate, once every hour or two, will be found useful. In a few 
obstinate cases cocaine muriate, in doses of one-twentieth or one- 
fifteenth of a grain, answered well; in others, arsenous acid, every 
two hours, a two- or three-hundredth part of a grain (one-third or 
one-fifth of a milligramme). 

One of the early complications is " rheumatism." It makes its 
appearance often on the third or fifth day. In some cases it is mus- 
cular, and then mostly confined to the lower extremities ; in others 
articular, but with less swelling than we are inclined to expect. 
Indeed, articular rheumatism in children exhibits the usual symptoms 
to a less characteristic degree than in adults, but they are so pro- 



214 INFECTIOUS DISEASES 

nounced as not to be mistaken. This rheumatism ought to be treated 
at once, for endocarditis complicates it in infancy and childhood very 
much more readily than in advanced age. Most of the cases of scar- 
latinal endocarditis carried into later life are due to rheumatism. The 
joints ought to be well covered with soft cotton, and sodium sali- 
cylate given every two or three hours, in doses of from four to ten 
grains (three to ten decigrammes). 

Endocarditis and pericarditis, without rheumatism, are rare. Ul- 
cerous endocarditis I have not seen except with serious general sepsis, 
caries of bones, thrombosis of sinus, and other symptoms of a general 
pyaemia. 

Suppurative inflammations of joints are very rare. They are the 
cause, or part, of generalized pysemia. This can sometimes be pre- 
vented by early surgical treatment. There is an affection of the 
epiphyses, however, which is very common and differs from the above. 
It consists in extensive hyperemia, and possibly inflammation. Clin- 
ical observation yields quite a number of cases of infectious diseases, 
but mainly scarlatina, in which during convalescence, and long 
afterwards, the regions of the joints are swollen and painful. This 
epiphysitis is the cause of the rapid increase in the growth of children 
who have passed through scarlatina, but may also be the cause of 
serious changes, from simple " growing pains" to suppurative separa- 
tions of the epiphysis from the diaphysis. In every such case, during 
convalescence and afterwards, the joint ought to be well supported 
by soft splints and emplastr. hydrarg., or iodoform collodion, abso- 
lute rest enjoined, and phosphorus given in three daily doses of a 
two-hundredth of a grain (one-third of a milligramme), or more, 
several times daily. 

Complications with pneumonia and pleuritis are quite frequent ; 
the latter is apt to be purulent; if so, its existence explains in many 
cases the continuance of the high temperature. In every case, puru- 
lent or not, the indications are not those of an expectant plan of treat- 
ment. Both general and cardiac stimulants and tonics are required, 
and pyothorax requires an operation always. 

Hemorrhages are not frequent, but ominous when they occur. 
Some appear, like the symptoms of generalized purpura, more towards 
the end of the malady ; some in the muscles in the third week or later, 
with the result of starting a more or less universal myositis ; others in 
the mucous membranes. Many are the result of embolic processes, 
and complicated with local gangrene. Spontaneous thromboses, how- 
ever, of the extremities or the cheeks ("noma") are not so frequent 
in scarlatina as in measles. 



SCARLATINA. COMPLICATIONS 215 

The presence of pemphigus during the eruption appears to indi- 
cate a high degree of vasomotor paralysis. It is an ominous compli- 
cation and requires stimulants as above. Urticaria is more trouble- 
some than dangerous. The inunction with pork, vaseline, glycerin, or 
lanolin — soothing and pleasing in most cases of scarlatina — may suf- 
fice to relieve it. Now and then mild alkaline lotions (sodium bicar- 
bonate in water, 1 to 100), or washing with carbonated alkaline 
waters (from the siphon) or with a proper dilution of carbolic acid 
(1 to 200), will prove beneficial. When the burning and itching are 
quite annoying, naphtol five parts and vaseline one hundred or one 
hundred and fifty may be tried to advantage. 

The rules for the general treatment of scarlatina must necessarily 
be very much like those applicable to all infectious diseases. Thus, 
in regard to them, and particularly to the debility and failure of the 
heart, I refer to my remarks on the treatment of patients suffering 
from typhoid fever. In scarlatina and eruptive fevers generally 
there is, however, an additional indication resulting from the parti- 
cipation of the skin in the process. Indeed, more than in other dis- 
eases, the hygiene of the surface must be attended to. During the 
course of the disease, particularly during desquamation, a tepid bath, 
with soap, ought to be given from time to time, and the temperature 
of the room and bed kept uniform. While the former is to be cool, 
the body must be well covered and kept warm. This is the more 
necessary, as nephritis may set in at any time during many weeks. 
This serious complication, it is true, may occur though the patient be 
kept in bed, in consequence of voluminous elimination of renal epithe- 
lia, and also, perhaps, of bacteric invasion ; but exposure and sudden 
changes of temperature will always hold their places in etiology in 
the minds of those who do not forget to notice the living clinical 
case besides the microscopical excrement. 

In this connection, while I reserve the subject of nephritis for 
some future occasion, I will only urge the advisability of beginning 
the treatment of scarlatinal nephritis with a moderate dose, from 
one-half to one grain (0.03 to 0.06), of calomel, repeated from time 
to time through the first two or three days. Its purgative effect, if 
too great, may be stopped by a small dose of opium given after every 
loose movement. 

There are a great many other complications, such as otitis media, 
purpura, noma, onychia, keratomalacia, etc. Each of them will be dis- 
cussed in their proper places. Mere combinations with other diseases, 
such as whooping-cough, measles, varicella, vaccinia, variola, and 
typhoid fever, do not add to, or alter, the indications for treatment. 



2i6 INFECTIOUS DISEASES 

At all events, the belief in scarlet fever specifics should be discarded 
in the present state of our knowledge. Neither magnesium nor 
sodium sulphite, nor sodium benzoate, nor belladonna has fulfilled 
the promises of its sponsors. What some special antitoxin will 
do remains to be seen. Marmorek's antistreptococcus serum is still 
in its experimental stage, though the number of favorable reports 
is increasing. If anywhere, an antitoxin is the only possible remedy 
which can hold out any hope in those cases which perish in a day, 
sometimes in the first few hours of the illness, under the influence 
of an overwhelming intoxication, and are not relieved by hot bathing, 
or purging, or stimulation. My own experience with Marmorek's 
antistreptococcus serum in very bad septic cases of scarlatina is fairly 
good. A few desperate-looking cases recovered under its use. Re- 
peated communications from the discoverer arrive at the same con- 
clusion, — viz., that the streptococcus found in man is the same, no 
matter where found and in what infections. " Varieties" are but 
apparent. The scarlatina streptococcus is no exception, and yields 
the same toxin as that formed by the others (it belongs to the 
group of those diastases which are destroyed by a temperature of 
70° C). 

Crede's preparations of soluble silver should be remembered in 
connection with scarlatina. In 1897 he recommended the soluble silver, 
first described by M. Carey Lea in 1889, for many sorts of infectious 
diseases. From being extensively used in puerperal sepsis, it extended 
its indications to erysipelas, scarlet fever, severe typhoid, pyaemia, etc. 
As usual, enthusiasm greeted its introduction and indifference scoffed 
at it. I believe it is of some use, and that it has benefited a good many 
cases under my observation. A fifteen-per-cent. ointment (" Crede 
ointment") is rubbed in once or twice daily, half an hour each time, 
best on those parts on which the integument is thin and the lymphatics 
superficial and numerous (inner aspect of thighs and forearms). The 
dose for an adult is one drachm (4.0), for a child from fifteen to 
twenty grains (1.0 to 1.25). It should be rubbed in until there re- 
mains but little discoloration from it, usually half an hour ; to accom- 
plish that, the skin should be moistened with a few drops of water. 
As the preparation ("colloidal silver") is soluble in twenty parts of 
(sterile) water, a few cubic centimetres of a one-per-cent. solution 
may be used subcutaneously. A solution of one part in from two 
to five hundred parts has been injected into a vein, and pills con- 
taining one-sixth of a grain (0.01) and one and one-half grains (0.1) 
of sugar of milk have been given internally : two to an adult, three 
times a day. My experience is limited to the " Crede ointment." 



MEASLES 



217 



12. Measles. 

The virus of measles appears to be more volatile (communica- 
tion even intra-uterine) than that of any of the other contagious dis- 
eases with the exception of influenza. Its communicability appears 
to be greatest during the prodromal stage, and the invasion takes 
place, in all probability, through the bronchial mucous membrane. 
The incubation may last from eight to fourteen days, the first four 
or five of which may be attended by some fever. During all this 
time, and during its whole course, the disease is contagious. 

Very few cases are seen during the first six months of life. 
After that it is common, and repeated invasions are frequent. In 
many seasons the mortality is very trifling; in some epidemics it has 
reached thirty-three per cent, of all the cases. The first epidemic 
occurring in regions where measles had not been known previously 
was found to be very dangerous, and those which occur after long 
interruptions are likely to prove very severe. Thus, the question 
whether the well should be separated from the sick will depend a great 
deal on the severity of the epidemic. 

The temperature of the room should be comfortable, about 70 ° F., 
a little warmer than in scarlatina, and the air moist. The light ought 
to be excluded to a certain extent, but not to absolute darkness. For 
a number of days the child should be kept in bed, unless very rest- 
less ; in that case it may be taken out, well covered. It is a good rule 
to keep the patient in bed a week after the disappearance of the fever, 
and in the house ten days or a fortnight more. Relapses are not 
uncommon, and those particularly who have an hereditary tendency 
to tuberculosis ought to be protected from exposure. Especial care 
must be taken during the cool or rainy season. 

Mild cases require mostly a hygienic treatment only; still, every 
case has its own indications. When there are otitis, bronchitis, pneu- 
monia, or dysentery, it is self-understood that the patient must be 
kept in bed during the continuance of the complication. Warm and 
dry weather and a sandy soil will permit a patient to leave the house 
sooner than would be permitted under other circumstances. 

Constipation may demand gentle treatment in the beginning. As 
a rule, an enema will suffice. Castor oil or the elixir of rhamnus pur- 
shiana (Nat. Form.) may sometimes be required. No drastic should 
be used because of the tendency to diarrhoea or dysentery prevailing 
in many instances. For the same reason no glycerin should be injected 
into the rectum. 

A convulsion in the beginning of the disease does not always 



218 INFECTIOUS DISEASES 

mean great harm. It takes the place of the chill in the adult, but 
is more dangerous because of the possibility of cerebral hemorrhages 
while it lasts. Therefore it ought to be cut short as soon as possible. 
Chloroform inhalations will relieve the spasm, chloral hydrate in- 
ternally, or in an enema, the persistent irritability. Warm bathing 
may be resorted to when, under these circumstances, the eruption is 
slow in showing itself. The head must be kept cool, the feet should 
be warmed. 

Epistaxis may be let alone while mild. Sometimes it relieves the 
congested mucous membrane of the nares. When severe it must be 
stopped. 

The organs of circulation do not often suffer in measles. Peri- 
carditis and endocarditis are met with very rarely, but Baginsky re- 
ported a case of purulent pericarditis and myocarditis. In epidemics 
of unusual severity heart-failure is of frequent occurrence. It is to 
be treated according to the principles laid down in the articles on scar- 
latina and typhoid fever. A peculiar feature in very severe measles 
is the frequency of thromboses (microbic?). Indeed, in no other 
infectious disease are they met with so often as in measles. The 
thrombi occur in the vulva, in the skin and subcutaneous tissue, about 
the face as cancrum oris (noma), and on the distal parts of the ex- 
tremities, particularly the legs. Disseminated purpura is not frequent, 
but gangrene of the skin is not at all uncommon. The odor of such 
gangrene, and of cancrum oris, is exceedingly offensive, and requires 
strong disinfectants and deodorizers. Thymol in solution of I to 
iooo, iodoform in powder or in vaseline ointment, or a mild solu- 
tion (one to two per cent.) of formalin will be found serviceable. 
The subject of noma will be discussed later. 

What has been called hemorrhagic measles is not always very 
malignant. In a great many cases it means nothing but the effusion 
of some hsematin into the eruption. The complication of the eruption 
with a simple erythema or with a mild pemphigus is mostly an indif- 
ferent matter; with extensive pemphigus it may be dangerous, and 
require early stimulation. 

The respiratory organs suffer mostly in measles. There is always 
catarrh of the nose, which may lead at an early period to tumefaction 
of the lymph-bodies around the neck. If such be the case the catarrh 
should not be let alone, but treated with gentle injections of a mild 
solution of salt water or boracic acid. The conjunctivitis connected 
with it requires tepid or cool application or instillation several times 
a day of a few drops of a two-per-cent. cocaine solution. It should 
have close attention, for it is sometimes followed by destructive pro- 



MEASLES. RUBELLA 219 

cesses of the cornea. A moderate amount of bronchial catarrh may 
be let alone, provided the cough is not very severe ; for severe attacks 
of coughing, even without much congestion or inflammation, may 
produce bronchiectasis or emphysema. Particularly is this the case 
when there is complication with pertussis. Here morphine may be 
given in sufficient doses. Bronchitis is rarely dangerous unless it be 
capillary. Broncho-pneumonia is always a serious complication and 
a very frequent one. In a number of cases its course is very rapid, 
accompanied by cyanosis and a very small pulse. Active treatment 
is required in these cases. The inhalation of oxygen will now and 
then bridge over urgent conditions. Warm bathing and cold affusion 
in a warm bath will be of service, for it is necessary that the patients, 
particularly small children, should cry. Unless they cry they will 
suffocate. Stimulant expectorants are in order, such as camphor, 
benzoic acid, or ammonium carbonate. Ammonium muriate is not 
sufficient. Cardiac stimulants are required at the same time, such 
as digitalis, sparteine, camphor, and musk. No depressing expec- 
torants should be given. Antimonials should be avoided, at any 
rate. 

There is always some catarrh of the larynx and sometimes a 
pseudo-membranous laryngitis holding, or caused by, either cocci or 
Klebs-Loffler bacilli. In the latter case the treatment is that of diph- 
theritic deposits. (See article on Diphtheria.) When the croupous 
symptoms are very urgent the air of the room ought to be filled with 
steam, and the patient encouraged to drink as much as possible, 
particularly alkaline waters. The internal administration of potas- 
sium iodide in moderate doses will do good service occasionally. 
So will an opiate, particularly at bedtime. In connection with the 
catarrhal affection of the nose, otitis is seen now and then. According 
to Schwartze, three per cent, of all the cases of otitis can be traced 
to measles. 

During all this time the kidneys ought to be watched. It is true 
that nephritis is by no means a frequent occurrence in measles, but it 
has been found often enough to justify the greatest attention. 

Cerebral complications have no special indications. Rules for 
their treatment will form the subject of a future discussion. Menin- 
gitis, as one of the localizations of tuberculosis which often follows 
measles, is not infrequent. 

13. Rotheln {Rubella). 
It has not yet conquered an undisputed place in nosology. There 
are still many who do not consider it a separate disease. The 



220 INFECTIOUS DISEASES 

eruption looks mostly like measles, sometimes like erythema, or urti- 
caria, or scarlatina. According to some, it begins, after an incubation 
of from nine to eighteen days, on the face ; others deny this, and speak 
of a suffused blush only. It lasts one or two days, becomes rather 
yellowish, and is followed by a very mild desquamation. Many cases 
have been described which were connected with catarrh of the respira- 
tory organs, of the conjunctiva, and of the throat (by no means 
always present; sometimes only a day before the eruption takes 
place), with glandular swellings (submaxillary, mastoid, axillary, 
inguinal) and very moderate fever. These are the cases which have 
been described under the name of rubella morbillosa, and would be 
diagnosticated by many, myself included, not as rotheln, or rubella, 
but as a mild form of measles. The redness of the fauces is not 
always intense; a punctated exanthema of the palate is frequently 
found; diazo-reaction is rare. If there be any such special disease, 
no particular treatment is required, except that of complications 
(catarrh, coryza, conjunctivitis, bronchitis, meningitis, arthritis, albu- 
minuria), most of which are rare. 



14. Mumps. 

Its incubation lasts a fortnight, and sometimes three weeks. Thus 
prevention by isolation can seldom be accomplished. The infection 
must be presumed to take place through the Stenonian duct ; that is 
why a careful hygiene of the mouth should be considered the best 
preventive. Often the patients do not feel very sick. Many do not 
take to their beds. In many cases covering the swelling with cotton 
is sufficient to protect it. When there is a great deal of pain nar- 
cotic applications may be made or ice applied. The latter certainly 
reduces the amount of swelling, although it may not shorten the 
course of the disease. I have often found the application of iodo- 
form collodion (one to eight or ten), made twice a day over the 
whole surface, quite successful. When there is a tendency to sup- 
puration, warm applications will favor it. Unless perforation take 
place into the mouth or the external ear, a large incision must be 
made in time and treated antiseptically. The diet must be that of 
all fevers, — fluid. A consecutive anaemia which is more frequent 
than the apparent mildness of the affection would seem to explain 
requires generous feeding, iron, mix, and a change of climate. Com- 
plications with otitis, nephritis, or orchitis have their own indi- 
cations. 



MUMPS. VARIOLA 221 

15. Variola. Variolois. 

Vaccination ought to take place early, for genuine variola in the 
first year is quite frequent among those not vaccinated. There are 
also many cases of variola between the eleventh and twelfth years 
among those not vaccinated. The small-pox reports of the German 
empire emphasize the fact that no case of variola (variolois) occurring 
in vaccinated children who had more than two cicatrices terminated 
fatally; nor was there a fatal case among those who were revacci- 
nated. There was no fatal case, where the vaccination marks were 
very distinct, between the thirteenth and forty-fourth years. The 
fact that none died that exhibited more than two scars appears to 
prove that the single mark customary among us is not sufficient. 
At all events^ many children vaccinated in the first year of life will 
undergo a successful revaccination when they are only from four 
to six years old. At that time revaccination ought to be tried, and, 
if unsuccessful, should be repeated from year to year. 

Disinfection of bedding, clothing, furniture, and dwelling, and iso- 
lation, are now recognized as absolute necessities in variola more 
than in any other disease. Thus little difficulty is caused by ill will 
or ignorance. Patients with variola ought to be kept cool and 
washed frequently with cold or tepid water; now and then an ether 
spray or an ice-bag over sore parts will be found quite agreeable. 
Fever is sometimes very high, and ought then to be modified by 
antipyretics. The delirium is sometimes so violent, bordering on 
mania, that the inhalation of chloroform or the administration of 
chloral hydrate is required. The influence of universal compulsory 
vaccination cannot be shown better than by the report of Baginsky, 
who has not met, in children, a single case of genuine variola and 
but few of variolois. The eyes ought to be covered with cold com- 
presses, sore eyelids covered with vaseline or zinc ointment. Super- 
ficial sores on the skin, and those which yield an offensive odor, should 
be treated with thymol, salicylic acid, or iodoform. Scabs must be 
removed from the nostrils so as to facilitate respiration; abscesses 
should be opened in time and disinfected, and complications treated. 
Septic symptoms require strong stimulants, general and cardiac. 
Two of the most severe complications are oedema of the larynx and 
laryngitis, which may require, on short notice, tracheotomy or intu- 
bation. 

After the disappearance of the feverish stage the patient ought to 
be bathed once every day or every other day, and inunctions of fat 
made all over the surface until desquamation is complete. 



222 INFECTIOUS DISEASES 

16. Varicella {Chicken-Pox). 

When varicella vesicles are in the mouth, they require washes with 
potassium chlorate (i to 30 or 50) ; when on the vulva, dermatol 
powder, or dermatol with cold cream (1 to 6 or 8). Constipation 
and gastric symptoms should be relieved. As the disease is very 
contagious, and not always mild, the child ought to be isolated, and 
on no account sent to school. Dissemination in schools and in 
dispensaries is an every-day experience. 

Bad cases must be kept in bed. Very few require medicinal treat- 
ment, except when there is local or disseminated gangrene, which I 
and many others have seen. In such cases local antiseptic applica- 
tions are required: aluminum acetate (1 to 100), potassium per- 
manganate (1 to 250 or 1000), formalin (1 to 50 or 100), or an 
ointment of resorcin (1 to 20 or 40), salicylic acid (1 to 40), or 
iodoform (1 to 6), or as a powder. Besides, alcoholic and other 
internal stimulants are demanded. A small number of instances of 
consecutive nephritis are now on record, as also in vaccinia ; thus 
the urine ought to be examined in every case for several weeks. 

17. Vaccinia. 
Irregularities in the development of vaccinia cannot always be 
prevented. As a rule, the inflamed areola and fever which indicate 
the beginning of immunity appear on the eighth or ninth, sometimes 
on the eleventh day. In the newly-born they are not well pronounced, 
and the success of the vaccination becomes doubtful. Still, it should 
be obligatory during an epidemic. The appearance of the vaccination 
vesicles (and pustules) will be delayed sometimes without an appar- 
ent cause. Accidentally (transmission by scratching) they may come 
on distant parts. A universal eruption (from no such cause) has 
been reported by Colcott Fox {Lancet, 1893, vol. i. p. 362), by Bagin- 
sky (" Lehrb. d. Kind.," 5th ed., p. 178), and by others. Very high 
temperatures with nervous symptoms may require, in rare instances, 
an antipyretic treatment ; they accompany mostly a high degree of 
local inflammation, which will be soothed by the application of cool 
water or of diluted aqua plumbi. Ulcerations result mostly from un- 
cleanliness and from scratching. They may be prevented by great 
care and cleanliness in vaccination, which requires the same asepsis 
as any other operation. No plaster should be applied before the 
wound is perfectly dry. Moreover, they appear to be more frequent 
when humanized rather than animal lymph is used. Iodoform or 
dermatol, in powder or in ointments, is indicated. The latter should 



VARICELLA. VACCINIA. ERYSIPELAS 223 

always be preferred. When the former is employed, however, no 
lymph should be taken from a vesicle that has been opened hours be- 
fore. Nor does it appear to be safe to use vaccine which has passed 
through more than three individuals. Axillary lymphadenitis dis- 
appears, with very rare exceptions, with the local inflammation. Rha- 
chitis, scrofula, and tuberculosis, when they are observed after 
vaccination, are accidental. Syphilis has been transmitted when the 
serum taken from the arm contained blood of a syphilitic infant ; that 
is another reason why animal lymph should uniformly be preferred. 
Erysipelas does not always originate from the margin of the local 
inflammation, but sometimes at some distance. Neither in regard to 
prevention nor to treatment can anything be said in addition to the 
remarks on erysipelas in general (p. 224). Diphtheria has arisen 
from vaccination wounds, when we knew less about its communica- 
bility and its preventability, and were more careless than we are 
(or ought to be) at present. The local treatment of such accidents 
(or sins) will be discussed under Diphtheria. Septicaemia may 
occur, nephritis also. At the very height of the reactive inflammation, 
or during the week succeeding it, urticaria may appear, or small or 
large vesicular eruptions, which are liable to disappear with the 
desiccation and falling off of the scabs. They should be considered 
as nervous outbreaks only, and not in the same light as an eczema 
— local or universal — which dates from the time of vaccination. The 
latter should not be taken for its real, but for its proximate cause 
(the fever) and opportunity. A case of universal psoriasis which 
originated in a fresh vaccination scar has been reported by Bethman. 

18. Erysipelas. 
It is so communicable that even a physician may carry it. Still, 
it is not probable that the healthy surface can be attacked by it. As 
in most cases of diphtheria, so in all cases of erysipelas, a sore surface 
forms the resting-place of the microbe (streptococcus). Erysipelas 
may make its appearance on an eczematous skin. On the head it 
sometimes escapes notice for some days. Excoriations of the anus 
and sexual organs, or slight injuries done by a pin or by the finger- 
nail, are sufficient to cause it. It often originates in the intertrigo of 
the infant or in the neighborhood of a vaccination mark. In the 
latter case it seldom appears immediately after vaccination, very often 
not before the second week or later. Chronic nasal catarrh is a 
frequent cause. Some children will have erysipelas extending over 
both cheeks one or more times every year. Small or large operation 
wounds are a frequent source : so is diphtheria, with which erysipelas 



224 INFECTIOUS DISEASES 

is occasionally complicated, and many cases are seen to take their 
start from a tracheotomy wound. In the newly-born it appears, 
as a rule, on or near the navel, and is generally connected with 
universal sepsis. Prevention of the disease will mainly depend on 
the removal or relief of the several causes which have been enu- 
merated. 

Every case of erysipelas should be isolated, and diet and general 
treatment be regulated on general principles. The local treatment 
may be quite simple in some cases. The erysipelatous surface may 
simply be covered with soft cotton, or a powder of talcum, or of 
amylum, or one part of salicylic acid with perhaps ten parts of zinc 
oxide and twenty-five of amylum. Applications of lead wash and 
opium or of zinc sulphate have been in general use for a long time ; 
also of solutions of sulphate of iron ; now and then the application 
or inunction of blue ointment. The latter I cannot advise because 
of the pain and irritation resulting. The inflamed surface has been 
covered with collodion. Infants and children will not bear it. Fer- 
reire has used, in a case of erysipelas on the leg of a child of two 
years and a half, a mixture of one part of resorcin in seven thou- 
sand five hundred of traumaticin (0.008 to 60.0). Cold applica- 
tions have been made, ice has been applied, and, where the extent 
of the erysipelas is limited, to great advantage. Neither the satu- 
rated solution of silver nitrate nor the solid caustic has been of 
advantage. 

Hueter recommended many years ago the subcutaneous injection 
of a two-per-cent. solution of carbolic acid round the inflamed surface, 
and claimed to have confined every case within its original limits. In 
place of that, I advised the application, not on, but around the ery- 
sipelatous area, of a mixture of one part of carbolic acid in eight, 
ten, or fifteen parts of oleic acid. I have treated many cases in that 
way, and most of them quite successfully. The mixture was rubbed 
into the surface around the diseased part at frequent intervals, or, 
when the erysipelas was confined to the extremity, a band or com- 
press soaked in the mixture was applied just outside the diseased 
part, not infrequently with the result of stopping the process. Instead 
of the carbolic acid as administered by Hueter, Ducrey uses a solution 
of one part of corrosive sublimate in one thousand of water, and re- 
peats the injections, which are to be made three centimetres apart, 
after twelve hours. A better plan, however, is, after all, to apply 
carbolic acid, one part dissolved in ten or fifteen of alcohol, directly 
to and beyond the surface, every hour or every few hours. It is 
readily absorbed, and may do good, but also harm by affecting the 



ERYSIPELAS 225 

kidneys. Thus in every case where it is to be applied the kidneys 
should be watched carefully, and particularly in young children. 

Washing with and applications of a solution of hydrargyrum 
bichloride in water (1 to 2000) have been highly recommended; 
also an ointment of resorcin live parts and vaseline and adeps lanae 
hydrosus (lanolin) aa ten parts. I have seen a few cases doing well 
with it, but I have been better pleased with a mixture of equal parts 
of ichythyol (ammonium sulpho-ichthyolate) and vaseline. In place 
of this a solution of ichthyol (2 to 10) in equal parts of ether and 
glycerin (10 to 30) has been employed. The compound tincture 
of benzoin may be painted all over and beyond the diseased surface 
once every hour or two hours. Absolute alcohol (ninety-nine per 
cent.), applied frequently, has rendered me excellent service in limit- 
ing the area of infection. That is what is aimed at and accomplished 
by the hedging in of the morbid process, an operative procedure 
invented by Kraske and Riedel, and introduced to us by Willy Meyer. 
Railfence-like scarifications are made under an anaesthetic, down to 
the rete Malpighii, partly in the diseased and partly in the healthy 
surface, double so as to cross one another and allow no loophole. 
Then corrosive sublimate (1 to 500) is rubbed into and kept applied 
to the wounds, in most cases with almost instantaneous, at all events 
rapid, success. The modification of this procedure, which is prac- 
tised in one of the large children's hospitals of Germany, by incising 
the diseased part and squeezing with the intention of removing the 
cedematous infiltration of the tissues, then scarifying deeply around 
it and rubbing in ichthyol, and repeating that " treatment" until scurfs 
are formed, appears to get dangerously near brutality. 

The internal administration of the tincture of chloride of iron has 
been considered a specific by many. That opinion is certainly based 
on an exaggeration of its merits. The preparation is, however, an 
antifermentative, and, while being a vascular stimulant, does not 
cause a rise of temperature in bad infectious diseases as it would do 
in the milder forms of fevers. 

Abscesses complicating erysipelas require large incisions and anti- 
septic treatment. Erysipelas of the neck is very often complicated 
with cedema of the larynx, and may require scarification, tracheotomy, 
or intubation. 

Meningitis, which frequently accompanies erysipelas of the scalp 
or of the naso-pharynx, has its own indications. It should not be 
forgotten, however, that many cerebral symptoms simulating menin- 
gitis, and mostly attended by high temperatures, are merely those 
of the toxin infection, and an antiseptic treatment may do good. The 

15 



226 INFECTIOUS DISEASES 

recovery of a young man observed with such symptoms lately I at- 
tribute solely to the large quantities of brandy administered. In such 
cases an efficient streptococcus antitoxin that Marmorek is trying to 
furnish would be of incalculable benefit, and Crede's ointment and his 
other preparations of soluble silver are certainly worth trying. The 
diet should be more stimulant (broths, alcohol in great dilutions) 
than in (the beginning of) most infectious diseases. 

19. Diphtheria. 
The morphological structure of almost all the pseudo-membranes 
in the throat, nares, larynx, and other places is identical. They have 
mostly been studied in the throat, where they are most frequently 
found. They consist of finely reticulated fibrin holding exudate cells, 
leucocytes, and some erythrocytes. When they are superficial, it is the 
epithelial protoplasm which is thus transformed ; when they are deep- 
seated, with a tendency to necrosis, ulceration, and, finally (in cases 
of recovery), cicatrization, it is the fibrillar basic substance of the 
connective tissue, mostly of the mucous membrane, sometimes also 
of the submucous and deeper structures. This view, which underlies 
the discussions in my "Treatise on Diphtheria" (1880), has been 
again forcibly demonstrated by P. Baumgarten (Berl. klin. Woch., 
Nos. 31 and 32, 1897). For years, however, it has been customary 
to differentiate between those pseudo-membranes which are caused 
by, or accompanied by, the Klebs-Loffler bacillus and those which 
contain cocci only. That these microbes do not establish any disease 
by their mere presence — that, on the contrary, they are met with to 
an indefinite degree in the mouths of the healthy — is well understood. 
Max Kober (Zeitschrift f. Hyg. u. Infect., vol. xxxi.) reports Klebs- 
Loffler bacilli in 18.8 per cent, of all people in contact with diphtheria 
patients. Personally he found them in eight per cent. People not 
in contact with such patients harbored Klebs-Loffler bacilli in from 
0.85 to seven per cent. To be considered pathological, or pathogenic, 
their presence in a pseudo-membrane in whatever stage of develop- 
ment is required. The Klebs-Loffler bacillus is found in its super- 
ficial layers only, not throughout the whole thickness of the pseudo- 
membrane, and not towards the macerating period; the coccus 
pervades its whole substance, and is even found in greater numbers 
in the deeper layers. To explain the absence of bacilli from these, 
it is assumed that they are destroyed by other microbes. Still, they 
are asserted — and that assumption has become an axiom, an article of 
faith — to evolve the toxin which gives rise to all the symptoms and 
dangers of certain forms of constitutional diphtheria. 



DIPHTHERIA. DEFINITION 2 2J 

Pseudo-membranes with Klebs-Loffler bacilli are called by pretty 
general agreement diphtheritic, those with cocci or with the " bacilli 
of pseudo-diphtheria" pseudo-diphtheritic. The " pseudo-diphtheritic 
bacillus" differs from the Klebs-Loffler very little, but is asserted 
by many to constitute an essential variety altogether. Such differ- 
ences as these, when met with, for instance, in the case of tubercle 
bacilli, are not admitted to be different varieties, but only modifica- 
tions of shape with modified virulence. In diphtheria the bacillus of 
" pseudo-diphtheria" is relegated to a second, inferior class, in spite 
of many objections. Lately, W. Spierig (Zeitschrift f. Hyg., vol. 
xxxi.) demonstrated that in a diphtheria epidemic all transitions were 
found between pseudo- and Klebs-Loffler diphtheria. Besides, cases 
may be met with that are only " pseudo-diphtheria," and still are 
followed by diphtheritic paralysis. 

Those cases which carry both bacilli and cocci are called mixed 
infections. It has been asserted that the second class is of little 
virulence and attended by but little danger. This opinion leads to 
cruel mistakes in their management both by boards of health and 
such medical men as are influenced by them. For not only are many 
uncomplicated cases very grave and fatal, but the mixed infections 
are the very worst forms met with in practice. Moreover, the strepto- 
coccus cases are contagious. Still, it is important to mention at once 
that the differentiation has its great practical weight. For it is only 
the first class, the bacillary diphtheria, and the third which are favor- 
ably influenced by antitoxin. The streptococcus variety does not 
share that advantage. What I have to say of treatment, however, 
refers — always with the exception of antitoxin — to all varieties. It 
remains for the attentive and experienced reader to apply it to the 
individual case, mild or serious, local or generalized, acute or chronic. 
Between these two latter varieties, however, accurate differentiation 
is impossible, because diphtheria has no limited course. There 
are cases that last a week or less ; there are those that take many 
months. Not a few of the latter (see my " Treatise") require, be- 
sides the general treatment, a very careful local diagnosis and treat- 
ment, as they are in part caused or prolonged by local ulceration, 
tonsillar or peritonsillar abscess, or concrement or other foreign 
body. 

Local diphtheritis, constitutional diphtheric infection, and diph- 
theric sepsis are different degrees of the same disease. The first may 
run a fairly mild course, or be the initial stage of the second and 
third. The treatment, accordingly, may be simple or complicated, 
successful or in vain. It should be preventive, local, increase the 



228 INFECTIOUS DISEASES 

power of resistance to the toxin prepared by the bacilli and floating in 
the circulation and in the tissues, be directly antidotal, and be aimed 
against the results of the disease, such as swelling of the lymph-nodes, 
laryngo-stenosis, nephritis, and paralysis. In many cases it may be 
necessary to fulfil only one or two of these indications; in others 
a combination of measures and remedial agents may be demanded. 
Diphtheria is one of the diseases in which it is easy to do too little, 
but also to kill the patient in the hurry of fighting the disease. 

The treatment should be mainly preventive. In the light of the 
fact that the contagion of diphtheria need not be direct, but may be 
carried by persons who are not themselves affected, it will readily be 
seen how difficult it is to prevent or to escape it. Herbert Peck re- 
ported (London Lancet, December 14, 1895) the case of house B, 
which was probably infected by the father of the family, who himself 
did not suffer from the disease. His son did not suffer, though there 
were germs in his throat, but he carried diphtheria to house C, whence 
it was taken to house D. This is only an instance of a large class. 
To what extent the bacilli and cocci in the mouths of healthy persons, 
where they are frequently found, may infect others it is yet impos- 
sible to tell. That may depend on circumstances concerning which 
we have not yet much knowledge. We know, for instance, that saliva 
is to a certain extent a disinfectant, but also that it is least so for 
the diphtheria bacillus (and the pneumococcus). It is also probable 
that a recent invasion is not so dangerous as older ones, which 
attain a higher degree of virulence when remaining some time in 
the crypts of the tonsils (E. Lexer, Arch. klin. Chir., 1897, vol. liv.). 

As a preventive measure* every individual case of diphtheria de- 
mands isolation, during the winter on the upper floor of the house; 
the windows should be open as much as possible, furniture of any 
kind reduced to the least possible quantity, the room changed every 
few days and the bedding frequently. 

To what extent the infecting substance may cling to surroundings 
is best shown by the cases of diphtheria springing up in premises 
in which diphtheria had not occurred for a long time, but which had 
not been interfered with; and best, perhaps, by a series of observa- 
tions of autoinfection. When a diphtheritic case has been in a room 
for some time, the room, bedding, curtains, and carpets are infected. 
The child is getting better, has a new attack, may again improve, and 
is again stricken down. Thus I have seen them die ; but also improve 

* See the New York Health Department's recommendations and rules 
(p. 207). 



DIPHTHERIA. PREVENTION 229 

immediately after having been removed from that room or that house. 
If possible, a child with diphtheria ought to change its room and bed 
every few days. 

The sick in crowded houses and quarters ought to be transferred 
to a special hospital, which ought not to be too large. That is why 
there should be many of that kind, as I hoped there would be when 
I commenced the agitation for the new departure twenty years ago 
(President's address, Med. Soc. State of N. Y. Trans., 1882). Mean- 
while the Willard Parker Hospital of New York, with its sixty beds, 
has been the only one of its kind for many years ; and only one-half 
of the money requested by the present efficient Health Department of 
New York City for necessary additions to fever hospitals and disin- 
fectant plants has been appropriated. The large amount of good 
the hospital is doing would grow in geometrical progression if there 
were, as there ought to be in a large and ambitious metropolis, half a 
dozen institutions of the same class, not only in behalf of the poor, 
but of the well-to-do also, both townspeople and strangers. I have 
advocated for dozens of years the erection of a hospital for the accom- 
modation of infectious diseases breaking out among the thousands 
of strangers staying in New York City at all times. So long as 
there is no place to go to, the cases of scarlatina, diphtheria, etc., 
are hidden in, and are infecting, the boarding-houses and hotels and 
the population at large. At present there is only one small private 
hospital of that kind in operation. 

When diphtheria breaks out in a house, either private or tenement, 
with no facility of isolation and no hospital in which to seek refuge, 
the well should be removed to a healthy place; in large cities, tem- 
porary homes ought to be provided for that purpose, to benefit the 
children of the poor. If the rich would but remember that their 
children will be affected through the many links between them and 
the poor (servants, messengers, schools, dresses brought home from 
the tailor or seamstress, or purchased in the stylish and expensive 
establishments which give out the work to tenement working-people 
and sweat-shops), their very egotism would compel them to do in 
their own interest what humanity does not appear to suggest to them. 
The sick should be reported to the health boards at once. The well 
children of a family with diphtheria must not go to school or church 
until a fortnight — the possible period of incubation, which some 
extend to twenty days — has elapsed since their last contact with the 
sick. Schools must even be closed now and then when an epidemic 
makes its appearance ; teachers should know how to examine a throat. 
In this respect the regular inspection of schools by medical men, as 



230 INFECTIOUS DISEASES 

introduced in New York, will prove an infinite blessing to the com- 
munity. The condition of the house is to be examined into and im- 
proved; attendants, servants, nurses and cooks, seamstresses and 
laundresses, teachers, shopkeepers, restaurant-keepers, barbers, hair- 
dressers, with their mild diphtheritic attacks and strong pecuniary 
interests, are frequent sources of infection. In times of common 
danger, public places, theatres, ball-rooms, dining-halls, public vehi- 
cles, hackney-coaches, and railroad-cars should be examined by the 
authorities. There must be no clashing permitted between the public 
good and the individual money-bag. Clothing, bedding, room, and 
house should be thoroughly disinfected; articles used in the sick- 
room burned or soaked in a disinfecting fluid in the room, not carried 
over the house in a dry state; they are known to have started epi- 
demics of diphtheria where the disease was unknown, thousands of 
miles away, after months or years, when carried in travellers' trunks. 
The rooms should be thoroughly disinfected after a case terminated 
favorably or unfavorably ; the corpse disinfected, the funeral private, 
nothing removed from the house unless disinfected, no pieces of carpet 
thrown away to be picked up by beggars, no mattresses benevolently 
donated to the unsuspecting poor, and books from circulating libraries 
should be disinfected every time when coming from an infected house, 
and from time to time, on general principles, during the reign of an 
epidemic of diphtheria. 

Prevention can accomplish a great deal for the individual. Diph- 
theria will, as a rule, not attack a healthy integument, be this cutis 
or mucous membrane. The best preventive is, therefore, to keep the 
mucous membrane in a healthy condition, as I have tried to practise 
and teach these more than forty years. Catarrh of the mouth, phar- 
ynx, and nose should be treated in time. Many a chronic nasal 
catarrh, with big glands round the neck, requires sometimes but two 
or three daily salt-water irrigations (i to 130, warm) of the nose, 
and, if the children be large enough to do so, gargling. Particular 
attention should be paid to the following facts. The water, if without 
salt, irritates ; so does water cold or too warm. An average tem- 
perature of 90 F. will be found satisfactory. This treatment, how- 
ever, must be continued for many months, and may require years. 
Still, there is no hardship in it and no excuse for its omission. A. 
Caille's many eloquent appeals have done much to popularize it. The 
nasal spray of a solution of silver nitrate (1 to 500 or 1000), when 
there are erosions, will accelerate the cure. Its application should be 
repeated every other day for some time. Not infrequently has a 
treatment which was considered obsolete when I was young been of 



DIPHTHERIA. PREVENTION 231 

great service to me. It consists in the internal administration of the 
tincture of pimpinella saxifraga. It is certainly an efficient remedy 
in subacute and chronic pharyngitis and laryngitis. I generally give 
it to adults, diluted with equal parts of glycerin and water, a teaspoon- 
ful of the mixture every two or three hours, with the warning that no 
water must be taken soon after; children in proportion. 

Large tonsils should be resected and adenoid growths removed 
while there is no diphtheria; for during an epidemic every wound 
in the mouth is liable to become diphtheritic, and such operations 
ought to be postponed, if feasible. The scooping out of the tonsils, 
for whatever cause, I have given up since I became better acquainted 
with the use, under cocaine, of the galvano-cautery. From one to 
four applications to each side (also to the postnasal space) are 
usually sufficient for every case of enlarged tonsils or lacunar or 
deep-seated follicular amygdalitis ("tonsillitis"). It is advisable to 
cauterize but one side at a time, to avoid inconvenience in swallowing 
afterwards, and to burn from the surface inward. Cauterization of 
the centre of the tonsils may result in swelling, pain, and suppuration, 
unless the cautery is carried entirely to the surface; that is to 
say, the scurf must be on, or extend to, the surface, not remain inside 
the tissue. Another precaution is to apply the burner cold, press it 
on, and then heat. A strong hook, bent in a convenient angle, intro- 
duced into a follicular fistula, and torn through the superjacent tissue, 
will also cause cicatrization and a cure. 

Nasal catarrh and proliferation of the mucous and submucous 
tissues may require the same treatment, but, in my experience, the 
cases which demand it are less frequent than those in which the 
tonsils need correction. 

The presence of glandular swellings round the neck should not be 
tolerated. They and the oral and mucous membranes affect one 
another mutually. Most of them could be prevented if every eczema 
of the head and face, every stomatitis and rhinitis resulting from 
uncleanliness, injury, or whatever cause, were relieved at once. 
Painstaking care of that kind would prevent many a case of diph- 
theria, glandular suppuration, deformity, or pulmonary consump- 
tion. 

For its salutary effect on the mucous membrane of the mouth, 
potassium or sodium chlorate, which was long claimed by some 
to be a specific in diphtheria, or almost so, is counted by me among 
the preventive remedies. If it be anything more, it is an adjuvant 
only. It exhibits its best effects in the catarrhal and ulcerous condi- 
tion of the oral cavity. In diphtheria it preserves the mucous mem- 



232 



INFECTIOUS DISEASES 



brane in a healthy condition or restores it to health. Thus it prevents 
the diphtheritic process from spreading. 

This process is seldom observed on healthy, or apparently healthy, 
tissues. The pseudo-membrane is mostly surrounded by a sore, 
hypersemic, cedematous mucous membrane, to which it will then 
extend. Indeed, this hyperemia precedes the appearance of the diph- 
theritic exudation in almost every case. The exceptions to this rule 
are formed by those cases in which the virus may take root in the 
interstices, pointed out by Stoehr, between the normal tonsillar epi- 
thelia. Very many cases of throat disease occurring during the 
prevalence of an epidemic of diphtheria are those of simple pharyn- 
gitis, which develops into diphtheria under favorable circumstances 
only. These throat diseases are so very frequent during the reign 
of an epidemic, that in my first paper on diphtheria (Amer. Med. 
Times, August n and 18, i860) I based my reasoning on two hun- 
dred cases of genuine diphtheria and one hundred and eighty-five of 
pharyngitis without a visible membrane. 

These cases of pharyngitis, and those of stomatitis and pharyn- 
gitis which accompany the membranes, are benefited by the local 
and general effect of potassium chlorate. When the surrounding- 
parts are healthy or return to health, the pseudo-membrane re- 
mains circumscribed. The generally benign character of localized 
tonsillar diphtheria, which is apt to run its full course in from four 
to six days, has in this manner contributed to secure to potassium 
chlorate the undeserved reputation of being a remedy, the remedy, 
in diphtheria. The dose of the salt must not be larger than fifteen 
grains (one gramme) for an infant a year old, not over twenty or 
thirty (1.5 to 2.0) for a child from three to five years, in the twenty- 
four hours. An adult should not take more than one and a half 
drachms (six grammes) daily. These amounts must not be given 
in a few large doses, but in refracted doses and at short intervals. 
A solution of one part in sixty will allow a teaspoonful every hour or 
half a teaspoonful every half-hour in the case of a baby one or two 
years old. 

It is not too late to raise a warning voice against the use of 
larger doses. Simple truths in practical medicine do more than sim- 
ply bear repetition : they require it. For though the cases of actual 
potassium chlorate poisoning are no longer isolated, and ought to 
be generally known, fatal accidents are still occurring even in the 
practice of physicians. When I experimented on myself with half- 
ounce doses, nearly half a century ago, the results were some gastric 
and intense renal irritation. The same were experienced by Fountain, 



DIPHTHERIA. POTASSIUM CHLORATE. HEART-FAILURE 233 

of Davenport, Iowa, whose death from an ounce (30.0) of the salt 
has been impressively described in Alfred Stille's " Materia Medica," 
from which I have quoted it in my " Treatise on Diphtheria." His 
death from potassium chlorate induced me to prohibit large doses 
as early as i860. In my contribution to Gerhardt's Handbuch der 
Kinderkrankheiten, vol. ii., 1877, I spoke of a series of cases known 
to me personally. In a paper read before the Medical Society of the 
State of New York in 1879 (Med. Record, March 15) I treated of 
the subject monographically, and alluded to the dangers attending 
the promiscuous use of the drug, which had descended into the ranks 
of domestic remedies; and finally, in my ''Treatise" (New York, 
1880), I collected all my cases and the few then recorded by others. 
Since that time the recorded cases have become quite numerous. The 
facts are undoubted, though the explanations may differ. The proba- 
bility is that death occurs from methasmoglobinuria produced by the 
presence of the poison in the blood (Marchand, 1879), and consecu- 
tive nephritis, though Stockvis has tried, by a long series of experi- 
ments, to fortify my original assumption that the fatal issue was due 
to primary acute nephritis. 

There is in every individual case a certain danger which, though 
it be common enough in other exhausting diseases, is of particular 
moment in diphtheria, where it is most frequent, even in apparently 
mild cases. It may be averted by meeting it early. It is heart- 
failure. When it has occurred, the indications for treatment become 
as clear as they are urgent but often futile. When it is simply feared, 
a preventive treatment will save many a case. 

Heart-failure is usually developed gradually. It is foreshadowed 
by an increasing frequency and weakness of both heart-beats and 
pulse, by an occasional intermission, by unequal frequency of the beats 
in a given period (say of ten seconds), or by the equalization of the 
interval between systole and diastole and diastole and systole. This 
latter condition, which is normal in the embryo and foetus, is always 
an ominous symptom; so is the too close proximity of the second 
sound (so as to become almost inaudible) to the first. 

Heart-failure is due, besides the influences common to every dis- 
ease and every fever, to tissue changes in the myocardium, in the 
nerves, in the endocardium, and to the gradual formation of blood- 
clots. These changes may be caused by the ill-nutrition of the tissues 
resulting from every septic condition of the blood, or to specific 
alterations due to the diphtheritic process. Failure may ensue either 
after having given warning or without any. Thus, every case of 
diphtheria ought to make us anxious and afraid. Indeed, there is 



234 



INFECTIOUS DISEASES 



no safety and no positive prognosis until the patient is quite re- 
covered, and even advanced beyond the period at which paralysis 
may develop. 

Whatever enfeebles must be avoided; absolute rest must be en- 
joined. The patients must be in bed, without excitement of any kind ; 
take their medicines — which ought to be as palatable as possible — 
and their liquid food and evacuate their bowels in a recumbent or 
semi-recumbent position ; crying and worrying must be prevented ; 
the room kept airy and rather dark, so as to encourage sleep if the 
patients be restless; and restless they are, unless they be under the 
influence of sepsis, and thereby subject to fatal drowsiness and sopor. 
In no disease, except, perhaps, in pneumonia, have I seen more fatal 
results from exertion on the part of the sick, or from anything more 
fatiguing than a sudden change of posture. Unless absolute rest 
be enforced, neither physician nor nurse has done his duty. The 
latter must avoid all the dangers attending the administration of 
medicines, injections, sprays, and washes. Preparations for the same 
must be made out of sight ; every application should be made quickly 
and gently. On no account must a patient be taken out of bed for 
that purpose. I know of children dying between the knees of nurses 
who called themselves trained and had a diploma. 

Pharmaceutical preparations, such as digitalis, strophanthus, spar- 
teine, caffeine, besides camphor, alcohol, and musk, should not be 
postponed until feebleness and collapse have set in. These are at 
least possible, even probable ; and this is certain, that a cardiac stimu- 
lant will do no harm. It is advisable to use it at an early date, 
particularly in those cases in which, perhaps, antipyrin or phenacetin 
— the indications for which are certainly rare, as excessive tempera- 
tures are very exceptional — is given. Besides, it is not enough that 
the patients should merely escape death ; they ought to get up, cito, 
tuto, et jucunde, with little loss and speedy recuperation ; a few 
grains of digitalis or their equivalent — preferably a good fluid extract 
— should be given, in a pleasant and digestible form, daily. When 
a speedy effect is required, one or two doses of two or four minims 
each are not too large, and must be followed by smaller ones. When 
it is justly feared that the effect of digitalis is too slow, I give, with 
or without it, strophanthus, in doses of from one to six drops of the 
tincture, or sparteine sulphate. Of the latter an infant a year old 
will take one-tenth or one-fourth of a grain (six or fifteen milli- 
grammes) four times a day as a matter of precaution, and every hour 
or two hours in an emergency. 

Of the same importance are alcoholic stimulants. The advice to 



DIPHTHERIA 235 

wait for positive symptoms of heart-failure and collapse before em- 
ploying the life-saving stimulant is bad. There are cases which get 
well without treatment, but we do not know beforehand which they 
will be. No alleged mild case is safe until it has recovered. When 
heart-failure has once set in — and it will often occur in apparently 
mild cases — our efforts are too often in vain. Thus alcoholic stimu- 
lants ought to be given early and often, and in large quantities, thor- 
oughly diluted. There is no such thing as danger from them or 
intoxication in septic diseases. A few ounces daily may suffice; but 
I have often seen ten ounces (300.0) daily of brandy or whiskey save 
children who had been doing badly with three or four (90.0 or 
120.0).* 

Caffeine or, in its stead, coffee is an excellent cardiac tonic, except 
in those cases in which the brain is suffering from active conges- 
tion. For subcutaneous injections caffeine and sodium salicylate (or 
benzoate), which readily dissolves in two parts of water, is invalu- 
able for emergencies, in occasional doses of from one to five grains 
(six to thirty centigrammes) in from two to ten minims of water. 
From five to twenty grains (0.3 to 1.25) of camphor may be given 
daily, as camphor-water, or in a mucilaginous emulsion, which is 
easily taken. It does not disturb the stomach as ammonium carbon- 
ate is apt to do. For rapid effect it may be administered hypoder- 
mically in four or five parts of sweet almond oil, which is milder 
and more convenient than ether. Strychnine may be added regu- 
larly from the beginning of danger, and mainly in cases with little 
increase of temperature. Its effect is more than momentarily stimu- 
lating. A child of three years will take one-hundredth of a grain 
(one-half milligramme) three times a day, and more in an urgent case, 
and then subcutaneously. But the very best internal stimulant in 
very urgent cases is musk. I prefer to give it from a bottle, in which 
it is simply shaken up with a thin mucilage. In appropriate cases it 
ought to be given in sufficient doses and at short intervals. When ten 
or fifteen grains administered to a child one or two years old within 
three or four hours will not restore the heart's action to a more 
satisfactory standard, the prognosis is very bad. One of the latest 

* This has been quoted lately from a former edition of this book, as a 
sin or a crime, by Kassowitz. He might have quoted my name in connection 
with his statement. If I have performed any creditable acts in my life, my 
recommendation of large quantities of pure alcoholic beverages in diphtheria is 
among them. No " theoretical reasoning," no " experiments" outweigh clinical 
experience repeated thousands of times. Let Kassowitz or any other prohibi- 
tionist find me a clinician of renown who would wish to do without alcohol. 



236 INFECTIOUS DISEASES 

stimulants, highly praised, is validol (containing thirty per cent, of 
menthol). A few drops are to be given in acute collapse, with flying 
pulse, etc., and are credited with great successes. 

The local treatment of the pseudo-membranes of the fauces is a 
subject of great importance. To still look upon them as an excretion 
which needs no interference is incorrect. If it were possible to re- 
move or destroy them, it would be a great comfort; but they can be 
reached only in certain places, and just in those in which they do 
least harm. Pseudo-membranes on the tonsils, when circumscribed, 
are least dangerous. Almost all circumscribed forms of tonsillar 
diphtheria are among the most benign, at least so long as the process 
does not extend. Most cases of the kind run their mild course in 
from five to seven days, and it is these which have given rise to 
the many proposals to tear, scratch, cauterize, swab, brush, and 
burn. There are cases which do not show the harm done. But 
neither the galvano-cautery, nor carbolic acid, nor tannin and glycerin, 
nor iron perchloride or subsulphate can be applied with leisure and 
accuracy to the membrane alone, except in the cases of very docile 
and very patient children. In almost every case the surrounding- 
epithelium is scratched off or injured, and thus the diphtheritic 
deposit will spread. Besides, the pseudo-membrane of the tonsil is 
in part altered surface tissue (it always is wherever the epithelium 
is pavement), and not deposited upon the mucous membranes, from 
which it might easily be detached; it is embedded in the tissue. 
Whatever is done must be accomplished without violence of any 
kind. Nasal injections or irrigations can be made so as to wash the 
posterior pharynx and the tonsils sufficiently, and thus render use- 
less the special treatment directed exclusively to the throat. Besides, 
such treatment is easier, meets with less objection, and gives rise to 
less exhaustion than the forcible opening of the mouth. This fact is 
of great importance, as I shall show in connection with the local 
treatment of the nasal cavity. Where it is possible to make local 
applications without difficulty, the membrane may be brushed with 
tincture of iodine several times daily, or with a drop of rather con- 
centrated carbolic acid. Of powders I know only one the applica- 
tion of which is not contraindicated, — viz., calomel, perhaps also 
iodol. Even this may irritate by its very form. Everything that 
is dry irritates and gives rise to cough or discomfort. Whatever 
has, besides, a bad taste or odor, such as sulphur, iodoform, or 
quinine, must be avoided. Quidquid delirant medici plectuntur 
cegroti. Sugar has been recommended as a panacea, also table 
salt (!). 



DIPHTHERIA. LOCAL TREATMENT 237 

In bad cases of septic diphtheria applications of the tincture 
of the sesquichloride of iron have been highly recommended. The 
frequent doses of the tincture of chloride of iron introduced by me 
(see below) have the same, if no better, local effect. Loffler's solution 
of alcohol sixty, toluol thirty-six, and tincture of iron sesquichloride 
four parts is not preferable to many others. The injections of car- 
bolic acid or chlorine- water into the tissue of the tonsils are objection- 
able in most cases, if only for the reason that they strike the least 
dangerous locality. 

Hydrogen dioxide is a two-edged sword. It is certainly a dis- 
infectant, but in contact with mucous membranes it coagulates the 
soluble albumin of the tissue. More or less extensive discolorations 
and pseudo-membranous deposits are caused by it, which are quite 
often large enough to be mistaken for diphtheritic. When they fall 
off there are sore surfaces ready for another invasion of bacilli or 
cocci. Many such cases get well only when the dioxide is stopped 
and a simple local treatment with lime-water substituted. By some 
the injurious action is attributed to the presence of acid in the drug, 
while others assert that the acidity is the cause of its beneficial 
effect (!). 

For the purpose of dissolving membranes papayotin, or papain, 
has been employed. It is soluble in twenty parts of water, and may 
be injected, sprayed, or brushed on. I have used it in greater concen- 
tration, in two or four parts of water and glycerin, in the nose, throat, 
and, through the tracheotomy tube, in the trachea. One of the irre- 
pressible drug manufacturers and advertisers pushes the claims of a 
modification of the drug, which he calls papoid. For the same purpose 
trypsin is preferred by others. The mode of application of papa- 
yotin is no indifferent matter. When applied in powder, it resulted in 
constant irritation of the throat, while the patient otherwise was 
convalescent. The pharyngeal hyperemia and slight exudation disap- 
peared when mild alum washes were substituted. 

Diphtheria of the nose is apt to terminate fatally unless energetic 
local treatment is commenced at once. This consists in persevering 
disinfection and cleansing of the mucous surface. The disinfecting 
procedure must not be omitted long, because general sepsis results 
from rapid absorption through the surface, which is supplied with 
lymph-ducts and small superficial blood-vessels to an unusual extent. 
Disinfectant or merely cleansing injections must be continued every 
hour for one or more days. If they be well made, the consecutive 
adenitis, particularly that about the angles of the lower jaw, is soon 
relieved and the general condition improved. But there are cases in 



238 INFECTIOUS DISEASES 

which it is not the lymph-bodies that are the main gates through which 
constitutional poisoning takes place, but the blood-vessels only. In 
the incipient stage of such cases the discharge from the nostrils is more 
or less sanguineous ; in them the blood-vessels, thin and fragile, carry 
the poison inward with great rapidity without any swelling of the 
lymph-nodes. 

In a few cases injections are unsuccessful. They are those in 
which the whole nasal cavity is filled with membranous deposits to 
such an extent as to require forcible removal. Sometimes it is difficult 
to push a silver probe through them. This procedure may be repeated, 
the probe dipped in carbolic acid or wrapped in absorbent cotton 
moistened with carbolic acid of fifty or ninety per cent. After a while 
injections or irrigations alone will suffice. But now and then the 
development of pseudo-membranes is very rapid, a few hours suffice 
to block the nostrils again, and the difficulty is the same. 

The liquids which are to be injected should be warm and fairly 
mild. Solutions of sodium chloride (6 to 1000) ; saturated solutions 
of boric acid; one part of mercuric bichloride, thirty-five of sodium 
chloride, and five thousand of water, more or less ; or pure lime- 
water; or solutions of papayotin, or a solution of sodium hypo- 
sulphite, will be found satisfactory. From the selection of these 
remedies it is at once apparent that the objects in view are partly 
to wash out and dissolve and partly to disinfect. I have not men- 
tioned carbolic acid, which may be used in solutions of one per cent, 
or less. Its employment requires care, for much of the injected fluid 
is swallowed, and proves a danger to children of any age, but mostly 
to the young. 

Most of the syringes I find in my rounds are abominations. The 
nozzle must be large, blunt, and soft. After having recommended 
for many years the common hard-rubber ear-syringe, the sharp end of 
which was cut off, I now use always a short, stout glass syringe with 
soft-rubber mounting in front. 

When the children cannot, or must not, be raised, I employ the 
same solutions from a nasal cup, a spoon, or a plain hard-rubber 
atomizer, the nozzle being lengthened by a short piece of rubber 
tubing. These applications can thus be made while the children are 
lying down, every hour or very much oftener, without any or much 
annoyance. The nozzle should be large enough to fit the nostril. 
Sprays will never be so effective as injections or irrigations. 

For a day or two these injections of fluids, or sprays, must be 
made hourly. It is not cruel to wake the children out of their septic 
drowsiness, for it is certain death not to do so. 



DIPHTHERIA. THE NOSE. INHALATIONS 



239 



Injections of the nose are oftener ordered than judiciously made. 
Hundreds of times I have been assured that they had been made regu- 
larly, hourly, for days in succession ; still, there was a steady increase 
of glandular swelling and sepsis. I never believe a nurse to have made 
them regularly unless I have seen her doing it. They will run up their 
syringe vertically and not horizontally; the fluid will return through 
the same nostril. On the successful injecting or spraying of the nares 
hangs every life in a case of nasal diphtheria. I have long learned to 
look upon a neglect to tell at every visit how to make an injection as a 
dereliction of duty. This may appear a trifling procedure, but it is a 
safe one. The nurse must be able to tell you that at every injection 
the fluid returns through the other nostril, or through the mouth, or 
that it is swallowed. 

The procedure is simple enough, and need not take more than 
half a minute for both nostrils. A towel is thrown over the child's 
chest up to the chin, and the child half raised in bed by the person 
who is to make the injection. This person, sitting on the bed behind 
the patient, steadies the patient's head against her chest, while some- 
body else secures his hands. The syringe is introduced horizontally 
by the person sitting behind the patient, and gently emptied. No time 
must be lost in refilling and attending to the other side. There ought 
to be two syringes ready for use. When pain in the ears is com- 
plained of, in spite of great gentleness in injecting, — such cases will 
be found to be very exceptional, — more gentleness is required, or the 
spray, or pouring in from a spoon, or minim-dropper even, or, better, 
from a nasal cup, must take the place of the injection. But get used 
to the injections. 

Many sins are committed in doing this very simple thing. The 
unfortunate little one is allowed to see all the preparations, is worried 
and excited, and the necessary gentleness in the proceedings is 
neglected in too many cases. 

For the purpose of softening and macerating pseudo-membranes 
steam has been utilized extensively. Its inhalation is useful in catarrh 
of the mucous membranes and in many inflammatory and diphtheritic 
affections. On mucous membranes it will increase the secretion and 
liquefy it, and thus aid in throwing off the pseudo-membranes. 
Its action is the more pronounced the greater the amount of mucip- 
arous follicles under or alongside a cylindrical or fimbriated epithe- 
lium. Thus it is that tracheo-bronchial diphtheria, so-called fibrinous 
bronchitis, is greatly benefited by it. Children affected with it I have 
kept in small bath-rooms for days, turning on the hot water and 
obliging the patient constantly to breathe the hot clouds. Several such 



240 INFECTIOUS DISEASES 

cases I have seen recover under that treatment. Atomized cold water 
will never yield the same result. Nor have I seen the patented inhalers 
do much good. 

Still, where the surface epithelium is pavement rather than cylin- 
drical, and but few muciparous follicles are present, and the pseudo- 
membrane is rather immerged in, and firmly coherent with, the sur- 
face, — for instance, on the tonsils, — the steam treatment is less appro- 
priate. On the contrary, moist heat is liable in such cases to favor the 
extension of the process by softening the hitherto healthy mucous 
membrane. Thus it takes all the tact of the practitioner to select the 
proper cases for the administration of steam, not to speak of the judg- 
ment which is required to determine to what extent the expulsion of 
air from the steam-moistened room or tent is permissible. 

Steam can properly be mixed with medicinal vapors. In the room 
of the patient water is kept boiling constantly over the fireplace, pro- 
vided the steam is prevented from escaping directly into the chimney ; 
on a stove (the modern self-feeders are insufficient for that purpose 
and abominations for every reason) ; over an alcohol-lamp, if we can- 
not do better; not over gas, if possible, because of the large amount 
of oxygen which it consumes. Every hour a tablespoonful of crude 
oil of turpentine is poured on the water and evaporated. The air 
of the room is filled with steam and vapors, and thus contact with 
the sore surfaces and the respiratory tract is obtained with absolute 
certainty. 

The secretion of the mucous membranes is sometimes quite abun- 
dant under the influence of steam, but still more, like that of the 
external integuments, increased by the introduction of water into the 
circulation. Therefore, drinking of large quantities of water, or water 
mixed with an alcoholic stimulant, must be encouraged. Over a 
thoroughly moistened mucous membrane the pseudo-membrane is 
more easily made to float and to macerate. 

To evolve large volumes of steam the slaking of lime has been 
resorted to. It is both an old and an effective procedure. Not only is 
the object in view accomplished by it, but it is the best means of bring- 
ing- lime into contact with the morbid surface. In a room in which lime 
has been slaked everything becomes covered with it. Thus this 
method of profiting by the local effect of lime is decidedly preferable 
to the almost nugatory effect of lime-water sprayed into the throat. 

It was to fulfil the same indication of softening the pseudo-mem- 
brane by increasing the secretion of the mucous membranes that 
pilocarpine or jaborandi was highly recommended (Guttmann) as a 
panacea in all forms of diphtheria. There is no doubt that the secre- 



DIPHTHERIA. ADENITIS 241 

tion of the mucous membranes is vastly increased by its internal 
application and by repeated subcutaneous injections of the muriate 
or nitrate of the alkaloid, but the heart is enfeebled by its use. I 
have seen but few cases in which I could continue the treatment for a 
sufficient time. In many I had to stop it because after some days of 
persistent administration I feared for the safety of the patients. There- 
fore, as early as at the meeting of the American Medical Association 
at Richmond, in 1880, I felt obliged to warn against its indiscriminate 
use in diphtheria. Thus it has shared the fate of the hundreds of 
remedies and methods which have been declared to be infallible and 
found wanting. 

Diphtheritic adenitis, the swelling of the cervical glands near the 
angles of the lower jaw, to which I have alluded as an ominous 
symptom, points to nasal and naso-pharyngeal (mostly mixed) infec- 
tion. The main treatment consists in disinfection of the absorbing 
surfaces. 

Direct local treatment of the glands, if not entirely useless, is, at 
all events, of minor importance and efficiency. The application of an 
ice-bag of moderate size will render fair service. The use of one part 
of carbolic acid in ten of alcohol irritates both the surface and the 
patient more than it can do good. Inunctions may do some good by 
friction (massage) ; inunctions with some absorbable material in them 
may do a little better. The common potassium iodide ointment is 
useless ; potassium iodide in three or five parts of glycerin is more 
readily absorbed ; the same in equal parts of water, with a little animal 
fat and six or eight times its quantity of lanolin, gives an ointment 
which is so rapidly absorbed that iodine is found in the urine within 
a few hours. Iodoform may be utilized in the same way. Injections 
of iodoform in ether, which I suggested years ago, are too painful. 
Mercurial inunctions, those of blue ointment, require too much time 
for any effect to take place. Oleates are too irritating locally ; a lanolin 
ointment would prove more satisfactory by doing less harm. After 
all, however, the readiest method of reducing the swelling of the 
glands and improving the prognosis accordingly is that of cleansing 
and disinfecting the Held of absorption. The rare cases of suppuration 
in these glands require incision and disinfection. They are, however, 
as ominous as they are rare. There is, as a rule, little pus, but one 
or many local deposits of disintegrated gland-cells and gangrenous 
connective tissue. The incisions must be extensive; the scoop and 
concentrated carbolic acid should be freely used. In these cases 
hemorrhages may occur, sometimes very difficult to manage. I have 
seen some of them terminate fatally. In these carbolic acid must 

16 



242 INFECTIOUS DISEASES 

be avoided. Compression, actual cautery, and acupressure have 
rendered good service. Solutions of iron must be avoided, for the 
scurf formed is a shield, behind which deleterious absorption is going 
on constantly in such wounds, as it does in the uterus. Antipyrin 
in water (i to 5 or 2) is an excellent styptic. 

The internal treatment of an average case of pharyngeal diphtheria 
can be made to combine the indications of both internal and local 
administration. For more than forty years I have employed the 
tincture of the chloride of iron. It is an astringent and an antiseptic. 
Its contact with the diseased surface is as important as is its general 
effect ; therefore it must be given frequently, in hourly or half- 
hourly doses, even every twenty or fifteen minutes. An infant of a 
year may take three or four grammes (one drachm) a day, a child of 
three or five years eight or twelve grammes (two or three drachms). 
It is mixed with water to such an extent that the dose is half a tea- 
spoonful or a teaspoonful; a drachm or two drachms, with a small 
quantity of potassium chlorate (see above), in four ounces, allows 
half a teaspoonful every twenty minutes. No water must be drunk 
after the medicine. As a rule, it is well tolerated. There are some, 
however, who will not bear it well. Vomiting or diarrhoea is a con- 
traindication to persevering in its use, for nothing must be allowed 
to occur which reduces strength and vigor. A good adjuvant is 
glycerin, — a better one than syrups. From ten to fifteen per cent, of 
the mixture may consist of it. Now and then it is not well tolerated. 
When diarrhoea sets in glycerin should be discontinued. Still, these 
cases are rare ; indeed, the stomach bears glycerin very much better 
than the rectum. 

In connection with this remedy I wish to make a remark of 
decidedly practical importance. I know quite well that recovery 
does not always prove the efficacy of the remedy or remedies admin- 
istered ; but I have seen so many bad cases recover with chloride of 
iron, when treated after the method detailed above, that I cannot 
rescind former expressions of my belief in its value. Still, I have 
often been so situated that I had to give it up in peculiar cases. They 
were those in which the main symptoms were of so intense a sepsis 
that the iron and other rational treatment were not powerful enough 
to prevent the rapid progress of the disease. Children with naso- 
pharyngeal diphtheria, large glandular swelling, feeble heart and fre- 
quent pulse, thorough sepsis, besides irritable stomach, — those in 
whom large doses only of stimulants, general and cardiac, will pos- 
sibly promise any relief, — are better off without the iron. When 
the circumstances are such as to leave the choice between iron and 



DIPHTHERIA. MERCURY 243 

alcohol, it is best to omit the iron and rely on alcoholic stimulants 
mostly. The quantities required are so large that the absorbent powers 
of the stomach are no longer sufficient for both. Nor is iron suffi- 
cient or safe in those cases which are pre-eminently laryngeal. To 
rely on iron in membranous croup means waste and danger. 

In this latter form of membranous croup, diphtheritic laryn- 
gitis, or laryngeal, also in general (pharyngeal and nasal) diphtheria, 
the most useful internal remedy is mercury. Empiricism has often 
praised calomel in small and large doses. My acquaintance with 
mercury in this connection is not at all new. Many years ago I pub- 
lished (Med. Record, May 24., 1884) a number of my cases which got 
well under its use, at the same time that Dr. Thallon, of Brooklyn, 
published an article on the same subject. Since I have employed it 
(I prefer the bichloride), my conviction of the utter uselessness of 
internal medication in laryngeal diphtheria, so-called pseudo-membra- 
nous croup, has been thoroughly shaken. Until about that time I 
felt certain of a mortality of ninety or ninety-five per cent, of all the 
cases of laryngeal diphtheria not operated upon. These figures were 
not taken from small numbers, for I compared those of others with 
my own. The latter are not a few, either; for within thirty years 
(until about 1890) I have tracheotomized more than six hundred 
times, have assisted at as many more operations, and have seen at least 
one thousand cases of laryngeal diphtheria which were not operated 
upon at all. During the years from 1883 to 1890 I have seen no less 
than two hundred cases, perhaps many more. Among them recoveries 
have not been rare at all ages, from four months upward. The uni- 
form internal medication consisted in the administration of a dose of 
the bichloride every hour. The smallest daily dose ever given by me 
in the beginning was fifteen milligrammes (one-fourth of a grain) to 
a baby of four months ; this was continued a few days, and the dose 
then somewhat diminished. Half a grain (0.03) daily may be given 
to children of from three to five years, for four or eight days or 
longer. The doses vary from one-sixtieth to one-thirtieth (0.001 to 
0.002). They require a dilution of one in eight thousand or ten 
thousand of water or of whiskey and water. There is no stomatitis ; 
gastric or intestinal irritation is very rare. It occurred in a few cases, 
but then it was found that the dilution had not been sufficient, — one 
in two thousand or three thousand only. Whenever it exists, very 
small doses of opium will remedy it. 

The benefit to be derived from the remedy depends greatly upon 
the time of its administration. Tracheotomy or intubation is required, 
as a rule, after days only, and can often be avoided if mercury be given 



244 INFECTIOUS DISEASES 

in time. If the operation becomes necessary after all, the treatment 
must be continued diligently. Never have I seen so many cases of 
tracheotomy getting well, since 1863, as when the bichloride was being 
used constantly, since 1882. Nor am I alone with these favorable 
results. There are dozens of practitioners in New York City, besides 
Drs. Francis and J. Huber, with whose methods and results I am 
well acquainted, some of whom are connected with me in one or other 
capacity, who confirm the above statements. 

My experience with the bichloride has been mainly gathered in 
cases of laryngeal and bronchial diphtheria, so-called pseudo-mem- 
branous croup and fibrinous bronchitis ; it is in these that it has been 
particularly effective. Still, but few of these were quite localized 
affections. Our cases of diphtheritic laryngitis are mostly descend- 
ing, and complicated with either diphtheritic pharyngitis or rhinitis, 
or both. Not a few, mainly of the latter kind, exhibit constitutional 
symptoms of sepsis. Many such have also recovered. 

Another method of using mercury is that of sublimating calomel 
in doses of from ten to fifteen grains, to be inhaled every few hours 
under a tent. It is particularly adapted to pseudo-membranous 
laryngitis. 

In any case of diphtheria there may occur conditions and com- 
plications which yield their own indications and require the closest 
attention on the part of the practitioner. I need not here refer again 
to the frequent attacks of exhaustion and heart-failure which carry 
off a multitude of patients, unless they be met in time. What I have 
said in previous pages on heart-failure and its prevention (or treat- 
ment) holds good in diphtheria, if anywhere. Therapeutical nihilism 
destroys more lives than any number of direct mistakes in dosing. 

Nephritis, parenchymatous, interstitial, and glomerular, and the 
varieties of pneumonia are frequent complications or consequences 
of diphtheria. The treatment of either of them requires no particular 
recognition in this place. Nor does oedema of the glottis yield indica- 
tions differing from that occurring from other causes. Diphtheria of 
the skin and of the sexual organs requires disinfectant ointments. I 
have mostly relied on iodoform one part in from six to twelve of fat. 

Diphtheritic paralysis, though of various anatomical and histo- 
logical origin, yields in all cases a certain number of identical thera- 
peutical indications. These are : the sustaining of the strength of the 
heart by digitalis and other cardiac tonics. A child of three years 
may take daily, for a month, three grains (0.2) or its equivalent; for 
instance, one grain (0.06) of the extract. This is an indication on 
which I cannot dwell too much. Many of the acute and most of the 



DIPHTHERIA. ANTITOXIN 245 

chronic diseases of all ages do very much better by adding to other 
medications a regular dose of a cardiac tonic. While it is a good prac- 
tice to follow the golden rule to prescribe simply, and, if possible, a 
single remedy only, it is a better one to prescribe efficiently. 

Besides the above, there are other indications: mild preparations 
of iron, provided the digestive organs are not interfered with ; strych- 
nine or other preparations of nux, at all events. In ordinary cases a 
child of three years will take an eightieth of a grain three or four times 
a day (together 0.002). Local friction, massage of the throat, of the 
extremities, and of the trunk, dry or with hot water or oil, or water 
and alcohol, and the use of both the interrupted and continuous cur- 
rents, according to the known rules and the locality of the suffering 
parts, find their ready indications. The paralysis of the respiratory 
muscles is quite dangerous ; the apncea resulting from it may prove 
fatal in a short time. In such cases the electrical current, used for 
very short periods, but very frequently, and hypodermic injections of 
strychnine sulphate in more than text-book doses, and frequently re- 
peated, will render good service. I remember a case in which these, 
the occasional use of an interrupted current, and occasional artificial 
respiration by Silvester's method, persevered in for the better part of 
three days, proved effective. In a few cases of diphtheritic paralysis 
the use of antitoxin appeared to meet with success. Other forms of 
paralysis (hemiplegia, ataxia) demand a treatment like the above, 
modified by their peculiar circumstances or symptoms. 

In regard to antitoxin, there are but few opposing voices left. 
Not quite so efficacious as thyroid in myxcedema, it is more generally 
useful because of the vast number of cases benefited by it. There 
is no practitioner that has not at present the right — or rather the 
duty — to give it a place among his most reliable remedies. It would 
be a pity if many of us, on account of distance or other reasons 
for its inaccessibility, were deprived of its services and compelled 
to rely exclusively on the treatment detailed above. There are in the 
worst forms of diphtheria so many urgent indications every one of 
which should be fulfilled, that the antidote of the circulating poison, 
if not on hand, will be sorely missed. For such a specific antidote it is, 
though it has not the power to cure every case of diphtheria any more 
than quinine cures every case of malaria or mercury of syphilis. Not 
counting isolated cases spread over the journals, the three hundred 
original cases of Heubner, five hundred of Baginsky, one thousand of 
Roux, and the many hundreds of the hospitals of Paris and Vienna, 
besides those of our own country, yield a basis on which to establish 
calculations. All observers agree on this point, that the sooner the 



246 INFECTIOUS DISEASES 

antitoxin is injected the more certain is its effect. Some go so far 
as to assert that no case injected the first day need die. 

The doses to be administered are, according to Behring, as fol- 
lows : according to the severity of a case, six hundred, one thousand, 
or fifteen hundred " antitoxin units" should be injected into a part of 
the body which contains loose subcutaneous tissue and is not exposed 
to pressure. This dose may be repeated if the symptoms are not 
improved within a day. A " unit" is equivalent to one cubic centimetre 
of what is called " normal serum." Normal serum is the blood-serum 
of an immunized animal, which has been made so efficacious that one- 
tenth of a cubic centimetre will antagonize ten times the minimum 
of diphtheria virus fatal to a guinea-pig weighing three hundred 
grammes (ten ounces). 

It appears to be a fact acknowledged by all that there is rarely, 
if ever, an immediate bad result of the injection, which ought to be 
made into the subcutaneous tissue, not into the muscles. The point 
of injection should then be covered with antiseptic gauze or with 
iodoform collodion. Not infrequently, however, there is redness, ery- 
thema, or urticaria around the point of injection. Besides, some of the 
after-effects are liable to be very severe. Urticaria, polymorphous 
eruptions, petechias and sugg'illations, excessive perspiration, swelling 
of glands, severe pain and swelling in feet and limbs and joints, pruri- 
tus recti, severe diarrhcea and vomiting, nose-bleeding, and great 
debility have lasted for weeks, yet terminated in recovery. Dr. Rau- 
schenbusch observed on his four-year-old daughter, who took three 
times the dose while sick with diphtheria two years previously, pruri- 
tus, urticaria, vomiting, sopor, and heart-failure, after two hundred 
units injected for the purpose of immunization (Berl. klin. Woch., 
1897, No. 32). A few sudden deaths have also been reported. No 
connection between them and the antitoxin has been established in 
any case, and venturesome generalizing speculations are not able to 
shed light on obscure subjects. 

Dr. James Ewing* studied the effect of antitoxin on the number 
and nature of leucocytes. While leucocytosis begins a few hours after 
the invasion of diphtheria, and increases, mainly as regards myelo- 
cytes, up to the climax of the disease and steadily declines during con- 
valescence, — remaining high only in most of the bad and fatal cases, 
— antitoxin, according to Ewing, within thirty minutes after its in- 
jection, causes a reduction of the number of leucocytes. This reduc- 
tion affects specially the uninuclear leucocytes, while the proportion 

* New York Medical Journal, August 17, 1895. 



DIPHTHERIA. ANTITOXIN 247 

of well-stained multinuclear cells is increased. In favorable cases, 
after the injection of antitoxin the leucocytosis never again reaches 
its original height. In severe and less favorable cases the injection 
is followed in a few hours by more hyperleucocytosis and fever. In 
very bad cases the immediate result may be either rapid increase or 
decrease of leucocytes, and death. The multinuclear leucocytes found 
in the blood of favorable cases after treatment with antitoxin show 
increased affinity for gentian violet. This change may be observed 
within twelve hours after the injection, and its non-occurrence is a 
very unfavorable prognostic sign. 

The existence of the after-effects mentioned above is not denied 
by any of the most enthusiastic admirers of antitoxin, but it is asserted 
that no serious or lasting results follow, and that if every life threat- 
ened by diphtheria were known to be protected by enduring the unto- 
ward effects of the remedy, we should willingly submit to them in 
every case. The balance of what we know of antitoxin is thus far 
favorable, and this addition to our therapeutical powers will forever be 
remembered as creditable to Emil Behring. It is a pity that he should 
not have been satisfied with his epoch-making results ; if he were a 
clinician he would be less extravagant in the expression of his opinions 
and more modest. If he were he would not have been tempted to 
assert that organotherapy has accomplished nothing, that cellular 
pathology has proved sterile, that remedies combat main symptoms only, 
that medicine hitherto had therapeutical principles only but no thera- 
peutical experiments, and that (his) experimental therapeutics is in 
conscious opposition to medication (German Congress of Int. Med., 
June, 1897). 

Altogether, the effects of antitoxin injections are eminently favor- 
able. The fever of diphtheria is much lessened within or after a day, 
and the second fever-wave — so common between the third and the 
fifth days — is not often observed. The membrane is speedily disinte- 
grated and disappears on the sixth day or sooner, while in cases not 
injected with antitoxin it lasts eight days or longer. Besides, there 
are but few cases on record in which the membrane returned after 
antitoxin, and not many in which it grew larger. In 181 cases of 
Heubner there were but three relapses. Albuminuria and nephritis 
are common occurrences in diphtheria as early as the (second and) 
third day. Among these 181 cases, of those injected on the first 
day, five-sixths remained free ; on the second, two-thirds ; on the 
third, one-half; on the fourth, one-third. The results of Bagin- 
sky, Roux, and Widerhofer are similar. In 525 cases of Baginsky 
treated with antitoxin there were albuminuria in 40.95 per cent., clini- 



248 INFECTIOUS DISEASES 

cal nephritis in 12.57 P er cent., and post-mortem nephritis in 15.80 per 
cent. However, among 933 cases treated without antitoxin there were 
albuminuria in 42 per cent., clinical nephritis in 25.78 per cent., and 
post-mortem nephritis in 16.31 per cent., — rather a favorable show- 
ing for antitoxin. In his 525 cases, heart- failure was noticed as the 
cause of death in eight; it occurred in 5.69 per cent, of all the cases, 
while it took place in 10.9 per cent, of the 933 treated without serum 
from 1 891 to 1894. In Heubner's practice it occurred nine times, 
but was not fatal. 

It is asserted that whenever antitoxin is injected before laryngeal 
stenosis has developed the larynx will remain free. That is an exag- 
geration, but it is certain that both tracheotomies and intubations have 
become less in number, and the speedier disintegration of the mem- 
branes and the (almost general) discontinuance of their growth after 
the injection of antitoxin have made it possible for intubation to take 
the place of tracheotomy in nearly every case of operative interfer- 
ence. 

Paralysis is no less frequent in antitoxin cases than it was 
formerly. But we must not lose sight of the fact that it never was 
exclusively found in very bad cases, but quite often after mild ones. 
Perhaps it results more from a mild but protracted poisoning than 
from a sudden and severe one. It may be, also, that many cases 
which survive with antitoxin and develop paralysis would not have 
lived to become paralyzed under a less satisfactory treatment. 

The principal question, however, to be raised in reference to any 
medication in cases of serious disease is its life-saving power. In its 
issue of August 8, 1895, the Deutsche medicinische Wochenschrift 
published a preliminary result of its collective investigation of anti- 
toxin treatment. The report refers to 10,312 cases of diphtheria 
treated in the city of Berlin and outside. 

It showed that the milder cases, in which six hundred units were 
considered enough, did best; that those which from the beginning 
offered a worse prognosis were given more antitoxin and did not be- 
have so well. That means, among other things, that, in proportion, 
mild cases do better under any treatment than severe ones. It also 
proves the necessity of not relying on a single method of treatment 
exclusively. 

Among the most enthusiastic eulogizers of antitoxin there is 
none but admits failures. Many of these are attributed to insuffi- 
cient strength of the serum. Mere serum of an immune animal does 
not suffice. Others — and these are the most conclusive — depend on the 
insufficient power of resistance on the part of the patient. That is 



DIPHTHERIA. COMBINED TREATMENT 249 

why the antitoxin injection alone should not be relied on. Nutrition 
and alcoholic and other medicinal stimulation must be resorted to. In 
regard to other treatment the authorities differ. Some, like Escherich, 
Baginsky, and Roux, favor it, Escherich particularly after the mem- 
branes have fallen off. Heubner rejects it. At all events, there are 
but few left who maltreat the child by the former cruel methods of 
local applications and cauterizations. It should not be overlooked 
that the antitoxin does not destroy bacilli, which continue the evo- 
lution of toxin persistently. I have advised, whenever I had an 
opportunity, the combination of my mercurial treatment with the anti- 
toxin, for the reports on the efficacy of mercurial treatment as recom- 
mended by me (p. 243) are becoming more and more favorable. 
Benney's Australian reports are very conclusive.* Some New York 
friends, to whom I offered antitoxin, declined it, declaring them- 
selves fully satisfied with the results they obtained from mercury 
and intubation. On the other hand, a townsman of ours who handles 
antitoxin a good deal pronounces mercury and antitoxin to be in- 
compatible, .and believes that mercury will interfere with the effect 
of antitoxin. This assertion has not been proved, but shows the facil- 
ity with which postulates may be substituted for experience during 
a period of enthusiasm. No greater eulogy, both on mercury and on 
antitoxin, can ever be pronounced than the figures detailed by Dillon 
Brown and referred to below. 

These results tally perfectly with the very exhaustive report of 
the hospitals of the London Metropolitan Asylums Board (London 
Lancet, June 5, 1897), which for the year 1896 proves a great reduc- 
tion in the mortality of cases brought under treatment on the first three 
days of illness, the lowering of the combined general mortality to a 
point below that of any former year, the still more remarkable reduc- 
tion in the mortality of the laryngeal cases, the uniform improvement 
in the results of tracheotomy, and, finally, the beneficial effect produced 
on the clinical course of the disease (N. Y. Med. Rec, September 4). 

Additional statistics concerning the effect of antitoxin are too 
numerous to be reported here. The collective investigation of the 
American Pediatric Society, of 1895, the results of the Boston City 
Hospital and of numerous other institutions, and those of painstaking 
practitioners all over the world are unanimous in regard to its effi- 
ciency and to the lowered mortality following its use. The doses are, 
however, larger than those employed at first. Thousands of units are 
easily borne, and are required in bad cases. 

* Australian Medical Journal, January 20, 1895. 



250 



INFECTIOUS DISEASES 



So far as immunization through small doses of antitoxin (from 
three hundred to five hundred units) is concerned, it appears to have 
been accomplished, in the opinion of many ; but they all agree that it 
does not last over a few weeks. Those who know that diphtheria, once 
introduced, predisposes rather than protects will have no particular 
confidence in the effect of antitoxin as an immunizer, except to bridge 
over a number of dangerous weeks ; but as in full doses it saves the 
lives of many who are stricken, its sphere of usefulness is indeed 
extensive enough. 

20. Rheumatism. 

Acute articular rheumatism is frequent both in infancy and child- 
hood. 

Since I made this statement nearly thirty years ago,* after obser- 
vations extending over more than twenty years, a few authors have 
accepted and verified it; but the majority are still of the opinion, 
inherited from their predecessors, that infancy and childhood are 
immune or almost so. Thus, only seventeen years ago Edlefsen 
reported to the German Congress for Internal Medicine {Trans- 
actions, 1885, p. 323) but eleven cases of acute rheumatism under five 
years, none of which was younger than two. The assertion that the 
disease is rare under four or under two years is frequently met with. 

Nothing can be more erroneous. The frequency of valvular dis- 
eases, mainly of the left side of the heart, in children of from four 
or five years to adolescence ought to suggest the frequency of rheuma- 
tism ; for but few of them are due to scarlatina and very few to syphi- 
lis; almost all are secondary to rheumatism, than which there is no 
more frequent cause of cardiac disorder. They cannot be claimed as 
congenital, for the fact that very few of the fcetal diseases of the heart 
are found on the left side, and but a small number survive the first 
(or perhaps second) year, remains undisturbed. Nor is the number 
of rheumatic cases limited to those exhibiting cardiac symptoms ; for 
though endocarditis is of more frequent occurrence — compared with 
the number of cases — in the rheumatism of children than in that 
of adults (in whom from ten to twenty per cent, contract a permanent 
organic lesion of the heart), still, there must be, and are, many cases 
of acute rheumatism which run their full course without terminating 
in heart disease. In order to ascertain this, the heart must be watched 
in every doubtful case. Endocarditis is sometimes the first symptom 
of acute rheumatism in children, and precedes every other, even in 

* A. Jacobi, Acute Rheumatism in Infancy and Childhood, 1875, in a series 
of American clinical lectures, edited by E. C. Seguin, M.D., vol. i. No. 2. 



RHEUMATISM 251 

apparently mild cases, and pericarditis and myocardial changes are 
not rare. When the slightest symptom of chorea minor shows itself, 
the heart should also be examined together with the joints, for there 
are cases in which chorea is not the final development of rheumatism 
and rheumatic endocarditis, but the very beginning of the disease, and 
then referable to a rheumatic affection of the spinal membranes or of 
the heart muscle. 

All of these remarks I believe to be opportune because of the 
frequency of cases in which the persistent notion that rheumatism is 
a rare disease gives rise to an erroneous diagnosis — the ubiquitous 
" dentition," " worms," " malaria," and " colds" — and to false treat- 
ment. After all, a correct diagnosis is the foundation and sine qua 
non of sound therapeutics ; thus I shall, in this neglected instance, add 
a few words on the subject of diagnosis, which is sometimes quite 
difficult. 

Fever is a common symptom in small children; every physical 
disturbance raises their temperature. In acute rheumatism it is often 
but slightly elevated ; it sometimes rises at irregular times, being now 
and then highest about noon. The swelling of the joints is apt to be 
very trifling and is often overlooked; the pain (either spontaneous or 
on pressure) may be very much less than that resulting from fatigue, 
rhachitis, syphilitic bone disease, colic, or otitis. Thus in every doubt- 
ful case of discomfort or pain the joints and heart should be examined 
for rheumatism. The diagnosis of acute articular rheumatism becomes 
quite difficult when but a single joint is affected, either temporarily or 
through the whole course of the attack, for a unilateral arthritis is 
very apt to be tuberculous or traumatic. Still, rheumatic monarthritis 
is observed principally in the hip- or knee-joint. Sometimes, after a 
week only or still later, the additional inflammation of other joints 
facilitates the recognition of the exact condition. Isolated inflamma- 
tory rheumatism also often fails to be recognized because of its being 
denominated " growing pain." The latter term dates from the medical 
nomenclature of past centuries, and ought to have been dropped long- 
ago. What has been called by that name is of variable origin and 
nature. Sometimes it is fatigue only. It may be neurosis of a joint 
with or without an cedematous swelling. I have seen a number of 
such instances in children of both sexes, about the shoulder-, hip-, and 
knee-joints mostly. Another affection which has been classed under 
the heading of " growing pain" is rhachitical or other epiphysitis and 
congestive swelling of the intermediate cartilage of the long bones. 
It is of frequent occurrence, without a perceptible cause besides the 
physiological hyperemia which is required for normal growth, and 



252 INFECTIOUS DISEASES 

liable to become pathological ; it is often noticed in convalescence 
or recovery from infectious diseases, particularly scarlatina. Still, 
the large majority of attacks of " growing pain" mean rheumatism ; 
it is the failure to appreciate this fact that constantly gives rise to 
mistakes in diagnosis and neglect in the administration of both pre- 
ventive and curative measures. 

That a rheumatic affection of one or more joints should not be 
mistaken for scurvy (joints hardly ever affected) or for poliomyelitis 
is self-understood. 

Rheumatism of the cervical part of the vertebral column is apt 
to be very painful and attended by high fever, stiffness of the neck, 
retracted head, delirium, and sometimes vomiting. Some of these 
symptoms are those of cerebral meningitis, and errors in diagnosis 
are easily made. Stiffness of the dorsal part is not always osseous, 
but sometimes rheumatic (ligamentary and muscular apparatus). 

There is no uniform cause or character of rheumatism. Staphylo- 
coccus aureus and pyogenic streptococci, mainly streptococcus citreus 
and diplococcus, have been met with. Their virulence is not always 
the same; its modification may explain the vehemence or the mildness 
of the attacks and the many varieties between a hardly perceptible 
pain and the worst symptoms of pyaemia. Does that mean that one 
or all of them are the origin and fountain of rheumatism, and that 
perhaps the latter is the result of many different infections by pyogenic 
cocci whose virulence is lessened? Besides, there are certainly cases 
of " rheumatism" which are not microbic ; those connected with 
psoriasis seem to be neuropathic, those with erythema multiforme non- 
microbic, and the inflammations of joints occasionally caused by 
(Klebs-Loffler) diphtheria antitoxin are surely not so. 

The essential character of rheumatism becomes still more dubious 
when we consider those cases of joint inflammation whose connection 
with known infectious diseases can be proven. They are called rheu- 
matoid, and exhibit either pain or inflammation or suppuration. They 
follow typhoid fever, dysentery, parotitis, gonorrhoea, pneumonia, 
diphtheria, influenza, cerebro-spinal fever, scarlatina and other acute 
exanthemata, hemorrhagic diathesis, and catarrhal angina, also syph- 
ilis. Pharyngitis has long been known to be connected with rheuma- 
tism, or rather to precede it. It is assumed with more than mere 
probability that the coccus invasion which is the cause of what we call 
rheumatism takes place through the pharyngeal lymph-bodies, the 
separate follicles, and the tonsils. That is why there is no better 
preventive than the hygiene and treatment of the mouth and throat, 
from mere systematic cleanliness to resection of tonsils and removal 



RHEUMATISM 253 

of adenoids. The contents of the joint were found to differ in gonor- 
rhoea, pneumonia, diphtheria, and erysipelas ; now and then the heart 
will be affected, mainly in scarlatina. In but few of them has salicylic 
acid the same effect as it displays in the majority (only) of genuine, 
independent, acute rheumatisms. In most of them antipyrin (with 
or without salicylates) acts better than salicylates alone. In syphi- 
litic arthritis, however, it has no effect at all ; iodides only are useful. 

Altogether, the treatment of acute articular rheumatism has been 
quite unsatisfactory down to a modern time. A few of the indications 
are furnished by the actual or alleged causes of the disease. By some 
it has been believed to be endemic; it is certain that some localities 
have been known to harbor a great many cases at the same time. In 
these, a change of residence, if practicable, ought to be resorted to, 
provided the individual case is but one of a great many in the same 
neighborhood. Contagion has now and then been presumed to cause 
the spreading of the malady, but the number of observations of the 
kind is very limited indeed. The greatest possible care bestowed 
on those sick with infectious fevers will prove a powerful preventive 
of rheumatic fever. The blood has been found to be changed during 
the latter affection : the red cells and haemoglobin are diminished, the 
white cells and fibrin increased. According to many writers, both 
chemists and physicians, the alkaline condition of the blood is less 
pronounced. This change, or the actual prevalence of acid in the 
blood, has also been either proved or assumed to exist in cachectic 
conditions of many kinds, in fevers, uraemia, leucocythaemia, diseases 
of the liver, in poisoning with acids, lead, and mercury, in pyaemia, 
typhoid fever, gout, and diabetes. In them, as in acute rheumatism 
also, lactic acid has been found in undue proportion. It is the same 
acid which has been found in over-exerted muscles ; still, when intro- 
duced into the circulation, it never produced articular rheumatism. 
The diminution of the alkali of the blood would justify at once the 
administration, through the whole course of an acute rheumatism, of 
alkaline salts, and particularly potassium ; the latter is greatly dimin- 
ished, according to Beneke, who, besides its relative absence, looks 
upon the impairment of nerve-power and the accumulation of organic 
acids as the main factors in the pathogenesis of rheumatism. 

Sudden changes of temperature are certainly among the causes of 
acute rheumatism. Cold and moist weather, moist houses, and expo- 
sure to wind and rain will bring it on. This effect may be immediate, 
and consists in the sudden suppression of the cutaneous circulation and 
elimination, or gives rise, by reflex action, to vasomotor or trophic 
disturbances in the joints. Particularly is that so in those who have 



254 INFECTIOUS DISEASES 

inherited a morbid disposition. Such an inheritance is not at all 
infrequent. I have seen acute rheumatism in several children of a 
rheumatic father or mother. The treatment of such cases must be 
mainly preventive. The tendency to be influenced by sudden changes 
of the surrounding temperature can be modified or removed by the 
systematic use of cold water. Children with a disposition to rheu- 
matism should have a daily cold wash, sponge, or bath. The former 
is the mildest mode of application. They may be rubbed down with 
a wet sheet, and afterwards with a warmed dry and coarse bathing 
towel. Those who have been strengthened by this procedure, or such 
as are stronger, may be sponged, or use a shower-bath for a few 
seconds, or a cold bath. These will be well tolerated and prove useful 
when the surface, mainly of the extremities, becomes warm after 
moderate dry friction. For such children as feel chilly after these 
applications treatment may begin with tepid water and alcohol (4 
or 6 to 1). I ought to add here that this treatment will accomplish 
its end best when throughout the rest of the day great care is used 
to protect the surface. A cold wash or bath, given to harden and 
strengthen, must be combined with warm clothing and bedding to 
protect. Nothing is more injurious than exposure of the surface to 
wind and rain. The bare knees and calves of the children of vain 
mothers are foolhardy provocations to the invasion of many serious 
diseases. Sea-bathing is a first-class roborant, except in the presence 
of heart disease. 

The swollen and painful joints must be protected against the 
pressure of blankets or painful handling by raising the bedclothes, 
keeping the limbs in a basket of proper size (waste-paper basket), and 
covering them thickly with cotton. Well-covered splints add greatly 
to the comfort of the patient. When pain and swelling are unusually 
severe, the application of an ice-bag or ice-cloth is advisable. Very 
young or anaemic children do not bear them long. Cold water will 
then take the place of ice-water or ice. A wet bandage or pack round 
the affected joint is often borne well and relished. It ought to be 
changed every hour or half-hour. Very anaemic and neurotic patients 
prefer hot and dry applications, mainly in those cases in which the 
pain is the principal symptom complained of. To relieve the latter I 
cannot advise the subcutaneous injections of carbolic acid which have 
been recommended; in very severe cases I have been compelled to 
administer a few drops of a solution of morphine hypodermically. As 
a rule, however, morphine oleate or a mild solution (from two to 
four per cent.) of cocaine muriate on the skin, chloroform lini- 
ment brushed on, chloroform poured into the cotton surrounding the 



RHEUMATISM. THE HEART 255 

joint and retained by oil silk, or a very mild galvanic current now 
and then, also the application of oil of wintergreen and of ointments 
containing ten or twenty per cent, of sodium salicylate will give some 
relief. 

The swelling of the synovial membranes and ligaments in retarded 
convalescence or chronic cases taxes the patience of both the sick and 
the physician. Vesicatories kept on for half an hour only, and fre- 
quently repeated; the wet bandage or pack snugly applied so as to 
compress gently ; compression by bandages or collodion ; gentle 
massage; and the galvanic current daily applied find their indica- 
tions in many and various cases. Iodine will come in for its share 
of usefulness. Besides the internal administration of the iodides 
(potassium or sodium, or both combined, in doses of from five to 
twenty grains daily [0.3 to 1.25]), the external applications will be 
found beneficial. The official ointment will act through the gentle 
handling and kneading necessitated by its use. Solutions of potas- 
sium iodide in glycerin will act better, but are inferior to the lanolin 
ointment referred to in a former chapter. Superior to all, however, 
is the application, twice daily, of one part of iodoform in from eight 
to fifteen of collodion or flexible collodion. It is brushed over the 
swollen part copiously, and allowed to dry while the limb is kept 
absolutely at rest for ten minutes. Only such scales as become de- 
tached spontaneously may be removed ; otherwise the next applica- 
tion is made on top of the preceding ones. Very old cases, with 
chronic effusion into the joint, require aspiration and washing out. 
These manipulations have become safe in the hands of every physi- 
cian who has learned the use of soap and of disinfectants on himself 
and his instruments since operative surgery availed itself of the im- 
mense progress made in pharmacological laboratories. 

Endocarditis demands absolute rest, both of the organ and the 
body. Every exertion will prove injurious. Thus an occasional dose 
of opium or of a bromide, or of both combined, and the use of potas- 
sium iodide in daily doses of from one-half to one gramme, have 
a good effect. The application of an ice-bag to the cardiac region, or, 
when that proves too heavy, an ice-cloth, acts very favorably indeed. 
But not every murmur means endocarditis ; it may be the result of 
muscular incompetency or irregular contraction only, and quite tem- 
porary; it is sometimes observed in cases of but moderate severity, 
and mainly combined, or alternating with, or preceding chorea minor, 
which now and then makes its appearance in the very earliest period 
of acute rheumatism. Both chorea and endocarditis can be mitigated 
or prevented by early attention. If every case of incipient rheumatism 



256 INFECTIOUS DISEASES 

were sent to bed, if no case of " growing pain" were allowed on the 
play-ground or at school, many a life-long ailment or early death 
would be avoided. 

The temperature is rarely high, or rather there are a great many 
cases of articular rheumatism in infants and children in which the 
temperature is as little elevated as the rest of the symptoms are 
urgent. But there are such as have rectal temperatures of from 104 
to 107 F. and more. It is in these that delirium and other cerebral 
symptoms, with paralytic respiration and collapse, may make their 
appearance, and that the most efficient antipyretics must be employed ; 
among them the cold pack, as described in a former chapter, applied 
to the trunk and lower extremities as far down as the knees, is the 
readiest and most effective remedy. It is particularly indicated in cases 
complicated with endocarditis; it is in these that antipyrin and phe- 
nacetin will not always have a pleasant effect. All of them are inferior 
to sodium salicylate as regards antirheumatic and antipyretic action. A 
child of three years may take from six to ten grains (0.4 to 0.6) every 
two or three hours, for one or more days. This is the less dangerous 
the more the symptoms of overdoses are understood. When they 
appear (mainly the brain symptoms, tinnitus, stupor, paralytic or inter- 
rupted, sighing, respiration) ample time is given for the discontinu- 
ance of the drug; a single large dose for the night, of from ten to 
twenty-five grains (0.6 to 1.5), succeeds better, sometimes, than the 
many smaller ones. As a rule, sodium salicylate mitigates the symp- 
toms of pain, swelling, and fever very soon. Many of the patients feel 
very much better after the lapse of a day; then the doses may be 
diminished or administered at longer intervals. Longer than from 
three to five days it ought not to be given ; if no effect, or an insuffi- 
cient one only, be obtained after that time, no further reliance need be 
placed on it. Then antipyrin, aspirin, from eight to twenty grains 
(0.5 to 1.25) daily, or phenacetin may accomplish what the salicylate 
failed in. In the same way salol, salicin, and cresotic and benzoic 
acids have been recommended. Lactophenin has proved unsatisfac- 
tory. Salipyrin in three or four daily doses of from four to ten 
grains (0.25 to 0.6) acted more favorably. 

At the same time, particularly when there is a constant tendency 
on the part of the temperature to rise either permanently or period- 
ically, quinine sulphate (or another preparation of the drug) may be 
administered in one or two doses of from three to eight grains (0.2 to 
0.5) each. The most opportune time is the period of remission, which 
mostly takes place in the morning. Alkaline salts may be given with 
the other medicaments, alkaline mineral waters, such as Seltzer or 



GONORRHEAL RHEUMATISM 257 

Vichy, or sodium bicarbonate, from a scruple to a drachm (1.0 to 4.0) 
daily, or potassium citrate or bitartrate, or one of the nitrates which 
have formerly been credited with almost a specific action. Vegetable 
acids have been warmly recommended, such as citric acid. They take 
the place of alkaline salts, inasmuch as they are eliminated as carbon- 
ates. Potassium and sodium iodides are esteemed very highly, — 
justly so, indeed, — particularly as the tendency to chronicity renders 
desirable the persistent action of a powerful absorbent. Of the other 
remedies which have been given for their alleged specific effect (colchi- 
cum, colchicin, veratrum, aconite), I have seen but little result in acute 
rheumatism of infancy and childhood. They, too, render better service 
in cases which have become or are fast becoming chronic. 

During the attack of an acute or subacute articular rheumatism 
the diet should be strictly milk, farinaceous food, light vegetables, and 
fruit. Meat and alcoholic beverages are positively forbidden. Plenty 
of water. 

Gonorrheal articular rheumatism is not excessively rare among 
infants and children, though direct sexual intercourse be not frequent 
at that age. It is not confined to one or a few joints or to those 
of the lower extremities ; it is mostly subacute ; the effusion is liable 
to be excessive and apt to be purulent. The latter condition, being 
dangerous partly to the joint and partly through its tendency to infect 
the body, must be watched carefully ; for it is often the beginning, 
or part, of a general pyaemia; in a few instances I have seen the eye 
destroyed by panophthalmitis in twenty-four hours, and the child 
died, after weeks of suffering, of the general infection. There are 
also cases of septic endocarditis. The cause is often what is easily 
taken for a common vaginal catarrh, but is gonorrhoea. The long 
time the latter may be concealed, unchanged in its contagiousness, 
within the vagina of the adult, and the facility of communicating it 
to the young by direct contact or mediate communication through 
towels, bedclothes, etc., yield a clue to certain otherwise unexplainable 
cases. In a small children's institution I saw a dozen cases at one time. 
The treatment of the diseased vagina has its own indications; that 
of the joint affected with gonorrhceal rheumatism must be more local 
than the average case. An aseptic puncture may be made for the pur- 
pose of ascertaining the contents of the synovial cavity. If there be 
pus, it must be removed and the cavity washed out, thoroughly disin- 
fected, the limb rested on a splint and gently compressed ; if serum in 
large quantity, puncture may become necessary when other treatment 
proves unavailing. Otherwise gentle but steady compression by band- 
ages, with or without mercurial plaster underneath, or by iodoform 

17 



258 INFECTIOUS DISEASES 

collodion, is indicated; at the same time the use of sodium salicylate 
and potassium and (or) sodium iodides must be continued a long time. 

During and after an attack of acute articular rheumatism there 
will be noticed, occasionally, small neoplasms on tendons and the inser- 
tions of muscles, on fasciae, and on periosteum, varying in size, num- 
bers, and sensitiveness, which consist of young connective tissue with 
numerous cells, last from a few days to several months, and give rise 
to but little elevation of temperature. Sometimes they are the very 
last, or only remaining, symptoms of the disease ; now and then a new 
endocarditis has been observed with them. This nodulated rheuma- 
tism, " rheumatismus nodosus," is very much more frequent in chil- 
dren than in adults. In the case of a boy of eight years the insertion 
of the occipital muscle was the principal seat of the nodules, dozens 
of which, from the size of a pea to that of a small hazel-nut, could 
early be distinguished. From syphilitic gummata, fibromata, gout, 
and cutaneous tubercles they can easily be discriminated. Special 
therapeutics for this form, besides what has been mentioned, there is 
none ; but endocarditis is of frequent occurrence. 

Peliosis rheumatica is the name of a peculiar form of more or 
less localized purpura. In some cases of rheumatism a large number 
of small subcutaneous and cutaneous hemorrhages appear mostly on 
the lower extremities and mainly round the joints. Now and then 
they are painful, but frequently not sensitive at all. In this they do not 
differ from common purpura. In a number of cases of peliosis the 
heart was not found affected, and the inference has often been drawn 
that peliosis is not " rheumatism" at all. Indeed, purpuric hemor- 
rhages are often noticed in other infectious diseases (typhoid, measles, 
whooping-cough, pneumonia, Bright's disease, syphilis, mercurialism, 
pyaemia, etc., according to the number and virulence of cocci circu- 
lating in the lymph- and blood-currents) and not infrequently round 
the malleoli and the joints in general (maybe in consequence of the 
impediment to circulation resulting from the smaller amount of 
subcutaneous fat and consequent tension of the integument in those 
regions), and in a number of instances the accompanying articular 
pains of such constitutional diseases are best explained by the pres- 
ence of hemorrhages inside. Still, peliosis will sometimes appear quite 
early in acute rheumatism; these are the cases which were classified 
as a specific variety, and that is why peliosis was asserted to be a spe- 
cific rheumatic affection. If so, it requires antirheumatic treatment; 
but the structural condition of the walls of the blood-vessels (and in- 
sufficient innervation and the presence of specific bacilli?), which 
causes the hemorrhages, indicates the early administration of robo- 



CHRONIC ARTICULAR RHEUMATISM 259 

rants and cardiac stimulants through the whole course of the disease, 
and great caution in the doses and quantities of sodium salicylate, 
which has rather a disposition to increase the hemorrhagic tendency. 
Aspirin may take its place. 

There are a great many varieties, or rather degrees, of peliosis, 
similarly to what we know to take place in purpura. According to 
whether the hemorrhage takes place near the surface or in the deeper 
layers of the tissue, both the color and the massiveness of the hem- 
orrhage will differ. In some cases the result is an erythema, which 
has been called either papillosum or nodosum, from the differences in 
the results of inspection and palpation. It is observed in both severe 
and mild cases of articular rheumatism ; it is somewhat raised above 
the level of the skin, sometimes deeply inserted and then circumscribed, 
and frequently found near the joints. In accordance with the indi- 
cations furnished by rheumatismus nodosus and peliosis, no special 
therapeutics is required for this form. 

Chronic articular rheumatism is rare in childhood. Moncorvo 
reports the case of a girl of two and a half years whose rheumatism 
began with an acute attack, became chronic, and was finally cured 
by the galvanic current administered for a long time in succession. 
The youngest case of mine, also a girl, was five years old. She was 
puny and feeble and her general nutrition defective. A number of the 
large and small joints, particularly of the hands, were affected, and 
the tumefactions of the ends of the bones were quite marked. There 
was neither an affection of the voluntary muscles nor of the heart, 
and no disease of any part of the nervous system, which Mitchell 
(1831) and Charcot (1868) found to be the cause of " arthropathia 
swellings. The treatment is about the same as that resorted to in 
the same disease when met in the adult. Sodium salicylate should 
be given in those cases only which exhibit acute exacerbations. Col- 
chicum, aconite, iodides will take its place, and will be required for a 
long period. Small doses of arsenous acid, from one-three-hundredth 
to one-five-hundredth of a grain (one-eighth to one-fifth of a milli- 
gramme) every two or three hours, will answer well. Prolonged 
warm, salt-water (cold or warm), and sulphur baths will improve 
many a case ; so will galvanism and massage. Others will be bene- 
fited by dry heat of a high temperature, in bed or in an apparatus, 
which increases tissue metamorphosis to a remarkable extent, mainly 
the amount of uric acid. As external treatment a diluted tincture 
of iodine, iodoform ointment, iodoform collodion, or potassium iodide 
and lanolin ointment may render good service. Narcotics are seldom 
required. Good results are obtained by the protracted use of alkaline 



2 6o INFECTIOUS DISEASES 

waters. From what little I have seen of chronic rheumatism in 
children, and the many cases of the same disease in adults, I recom- 
mend strongly the use of large quantities of water, to which is added 
from a scruple to half a drachm (i.o to 2.0) of potassium bicarbonate, 
as a daily dose ; also lithium carbonate in daily doses of from four to 
ten grains (0.25 to 0.6). Our natural lithia waters contain too little 
lithia to have any effect except through the large amounts of water 
consumed. 

Muscular rheumatism can be diagnosticated occasionally in very 
young children; in those from six to twelve years it is not quite 
rare. Its nature and symptoms do not differ from those in the adult. 
The neck, back, and shoulders are most frequently affected. The best 
preventive is the habitual use of cold water. Diaphoretics are not very 
useful. Narcotic and stimulating liniments find their own indications. 
Morphine oleate is of but little use; in a severe case I have injected 
a small dose of morphine with immediate and permanent effect. The 
interrupted current acts promptly in one or more sessions. Sodium 
salicylate, antipyrin, aspirin, and phenacetin have some effect, in 
proper doses and frequently repeated. Semmola's experience in a 
severe case of neuro-muscular rheumatism is worth remembering. 
The case was that of a woman of forty years, who suffered from stiff- 
ness and pain in a shoulder and right arm, with good passive motility 
of the joint. After the pain had lasted several months, massage, elec- 
tricity, quinine, and salicylic acid having proved inefficient, the patient 
was relieved in a few days by a few subcutaneous doses of one-twelfth 
of a grain of pilocarpine. 

It is in rare cases only that the rheumatic process in the muscle 
assumes the character of an inflammatory affection. Then there is, 
as in every myositis with a tendency to chronicity, a hyperplasia of the 
connective tissue between the fibrillse, the muscle becomes hard and 
somewhat shorter, and its electrical irritability grows less or disap- 
pears ; even the skin participates in the process. Such a case I once 
observed in a boy of twelve years. He was never entirely relieved, 
but greatly improved by massage, warm bathing, a mild continuous 
current, and the internal administration of hydrargyrum bichloride. 
The treatment was continued for more than a year. These cases 
appear to prove the identity or similarity of rheumatism, no matter 
whether in the joints or muscles (I. Adler and others). 

21. Influenza. 
Epidemic bronchitis (influenza) can be prevented only by avoiding 
contagion, which is even more difficult than it is to escape measles. 



INFLUENZA. PERTUSSIS 261 

Its treatment depends a great deal on the variety ; the catarrhal, gas- 
tric, and intestinal symptoms require early attention, for nervous 
exhaustion is imminent in every case, and many patients suffer more 
seriously from the sequelae than from the original attack. Antipy- 
retics cannot always be avoided. Phenacetin, antipyrin, and sodium 
salicylate, combined with a cardiac stimulant, may be thus employed, 
particularly when muscular pain is one of the prominent complaints. 
Quinine also finds its ready indication. Opiates are often required, 
either in small and frequent doses or in a single larger dose to secure 
sleep. Inhalations of steam, two per cent, of carbolic acid having 
been added to the water, have been highly recommended, but what- 
ever adds to the bronchial irritation and produces cough should be 
avoided. Rest in bed is required long after apparent recovery, for 
collapse and nervous symptoms of many kinds are liable to appear 
during convalescence, and there is no case, though apparently ever so 
mild, that may not prove grave. Besides vomiting, diarrhoea, high 
temperature, great lassitude, and all the symptoms of catarrh and 
inflammation of the mucous membranes, complications with serious 
forms of pneumonia, sometimes catarrhal and croupous in combina- 
tion, and pleurisy, of diseases of the heart and blood-vessels (throm- 
bosis, phlebitis) and the sensory organs, and of the nervous system 
(mental disorders included) are frequent. Osteomyelitis and laryngeal 
and tracheal perichondritis are occasionally met with, also inflamma- 
tions of joints, which are mostly intolerant of massage or compres- 
sion. Nephritis is an early complication. Among the ocular symptoms 
conjunctivitis is frequent, keratitis and iritis are met with, iridochoroi- 
ditis and retinitis are not so frequent as acute glaucoma. Now and 
then atrophy of the optic nerve has been observed. Otitis media with 
mastoid abscess is not uncommon; hemorrhagic myringitis requires 
incision. Meningitis and pyaemia are among the sequelae. Most fre- 
quent is utter exhaustion, which appears to be more than merely 
functional, and requires for weeks and months (years) the most care- 
ful and persistent roborant and stimulant measures. 

22. Pertussis. 
The mortality from whooping-cough in New York City is as great 
as that from typhoid fever. Twenty-five per cent, of all the cases 
under a year terminate fatally ; five per cent, of all those between the 
first and fifth years, and one per cent, of all those occurring after the 
fifth. Its direct mortality, however, is not the only danger, for not 
infrequently chronic laryngitis, pneumonia, emphysema, dilatation of 
bronchi, and the result of hemorrhages which occur during the attacks 



262 INFECTIOUS DISEASES 

(convulsions, paralysis either general or local, blindness) impair the 
health of the patient for many years or a lifetime. Thus the tendency 
to allow whooping-cough to run its full course on the plea that it is 
a self-limited disease, or that every child must have his whooping- 
cough, is not justified. 

The prevention of whooping-cough, which is a specific and con- 
tagious disease, is certainly not easy, for the reason that contagion 
may take place very suddenly, and through the first and second stages 
of the disease, both of which extend over a large number of weeks. 
Contagion may take place, whether or not the disease be occasioned 
by micro-organisms, by means of the exhaled air, or mucus, or the 
masses brought up by vomiting. Prevention means protection against 
the effects of all these factors. 

As the disease is spread by contagion only, isolation is an absolute 
necessity, difficult though it be. In public institutions it is well-nigh 
impossible. Thus no patient ought to be admitted to, or allowed to 
remain in, a public school or a hotel inhabited by children. Children 
with whooping-cough must not even be permitted to congregate in 
large numbers, because the cases will become more severe by mutually 
affecting one another. In one point only isolation is more effec- 
tive in whooping-cough than in other contagious diseases, — namely, 
that the disease does not appear to be carried by persons not thus 
affected. 

The air must be kept pure, uniform, and moderately warm. The 
patient should be out as much as possible. No draught, however, 
must be permitted. Utensils must be kept clean and be disinfected, 
and the masses brought up by vomiting disinfected, destroyed, or 
removed. The mucous membranes should be kept in, or restored 
to, a healthy condition, particularly those of the mouth and respiratory 
organs. No injudicious exposure must be allowed. The digestive 
organs must be watched, the stomach must not be full at any time, 
the bowels kept regular, the food digestible. 

So long as the microbic cause of the disease is not known (by 
different investigators different bacilli and cocci are charged with 
being its cause), and therefore no causal indication can be fulfilled, 
the objects of treatment are limited as follows: to relieve the severity 
and diminish the number of the attacks, to procure quiet nights, to 
stop the vomiting, to shorten the course of the disease, and to prevent 
detrimental consequences. 

An important indication is that of treating a catarrhal or inflamed 
mucous membrane. It is quite possible that a sore mucous membrane 
only is capable of admitting the contagion of whooping-cough as it 



WHOOPING-COUGH 263 

mostly does that of other infectious diseases, — for instance, diphtheria. 
Besides, by attending to the mucous membranes in time, the occur- 
rence of serious complications, such as pneumonia, may be prevented. 
Catarrh of the mouth and pharynx ought to be treated with doses of 
potassium chlorate of from half a grain to a grain (0.03 to 0.06) in 
a teaspoonful of water every hour, and a large number of expec- 
torants find their ready indications in such cases. All of those 
which have a depressing effect should be avoided, particularly anti- 
monials. Even ipecac should be given in small doses only. Alkaline 
waters have a beneficial effect. Ammonium muriate in doses of from 
half a grain to two grains (0.03 to 0.125) every hour or two hours 
will liquefy the viscid secretion of the bronchial mucous membrane. 
In a state of evaporation, as described in a former essay, it may be 
inhaled. The inhalation of other agents which have been recom- 
mended as expectorants may at the same time exhibit' their germi- 
cidal action, — the vapors of benzol, of carbolic acid, and of cresolin; 
the reputation obtained by gas-works in the treatment of whooping- 
cough is thus readily explained. 

The effect attributed to astringents in the treatment of whooping- 
cough is best explained by their action on the mucous membranes. 
Particularly alum and tannin have been so employed. Emetics have 
been recommended for the purpose of relieving the surfaces of sticky 
mucus difficult to remove. Copper or zinc sulphate, powdered ipecac, 
and turpeth mineral are the proper substances to be selected for that 
purpose. 

Schliep has seen good effects of the use of the pneumatic chamber 
in whooping-cough. He kept the children with their mothers or 
attendants in compressed air. In some cases a few sessions of two 
hours each were sufficient to relieve the patients considerably. In a 
number of cases from twelve to twenty sessions were required. In 
all of them he claims decided effects, not only in the reduction of the 
number and severity of the attacks, but also in the duration of the 
disease. The explanation of the good effects is looked for as well in 
the increased amount of oxygen inhaled as in the diminution of the 
hyperemia of the mucous membrane. I believe that the plan is a good 
one, particularly if it can be combined with the inhalation of tur- 
pentine. 

Caille (Arch. Ped., August, 1892) says that ozone inhalations have 
a very distinct curative effect as regards the duration and severity of 
the disease. 

Cases exhibiting a severe degree of pharyngitis and laryngeal 
hyperemia, particularly in children who have suffered a long time 



264 INFECTIOUS DISEASES 

from chronic inflammatory affections of these parts, will do well, so 
far as the local symptoms are concerned, under the use of the tincture 
of pimpinella saxifraga; half a drachm (2.0), mixed with water and 
glycerin, distributed over the twenty-four hours will be the proper 
dose for a child of from two to three years. 

Local treatment has been resorted to by many. The pharynx has 
been treated locally with a solution of quinine (Hagenbach), a two- 
per-cent. solution of resorcin (Moncorvo), a one-per-mille solution of 
mercuric bichloride, a one- or two-per-cent. solution of silver nitrate, 
a five-per-cent. solution of cocaine hydrochlorate, or a four- or six- 
per-cent. solution of potassium bromide. Applications of quinine 
mixed with sodium bicarbonate in different proportions, of mild solu- 
tions of salicylic acid, and of powdered sulphur have also been made 
directly to the larynx. Inhalations of sulphurous acid have been 
resorted to, besides those enumerated above, and extolled as highly 
as any which have been mentioned. If they prove anything, they 
and the great number of remedies recommended for the same pur- 
pose show the difficulty encountered in the treatment of whooping- 
cough, and the confidence of the practitioner in the patience and 
submission of his wards. Michael treats whooping-cough as a neu- 
rosis, with the same means he employs against other neuroses 
attributable (or attributed) to nasal irritation. He asserts that 
seventy-five per cent, of his cases of whooping-cough have done 
well when exposed to the influence of quinine, potassium bromide, 
benzol, tannin, boracic acid, salicylic acid, iodoform, cocaine, sodium 
bicarbonate, or prepared chalk applied to the mucous membrane of 
the nares. 

The internal administration of chloral hydrate, or croton chloral 
hydrate, was recommended by Lorey in 1879. The daily doses 
ranged from eight to fifteen grains (0.5 to 1.0). In all cases the at- 
tacks became less severe within a short time, but the disease itself 
was not shortened. Kennedy expresses himself very enthusiastically 
in regard to the effect of the remedy, which is given by itself or com- 
bined with potassium bromide. To procure an occasional good night, 
a single dose of from six to twelve (0.4 to 0.75) grains has rendered 
me good service. 

Rest and sleep should be enforced. W. W. Johnston's (Arch. 
Pcd., April, 1895) advice to keep children with whooping-cough in 
bed is good. In that way isolation, rest, and equable temperature are 
secured, and the results of the feebleness and dilatation of the heart 
are avoided. 

The inhalation of chloroform or, according to some, of ether can 



WHOOPING-COUGH. QUININE 265 

be recommended in those cases in which convulsions have either 
occurred during severe attacks, or in which the interruption of the 
circulation is such that cerebral hemorrhage or convulsions are to be 
feared. In the case of a very young infant I have administered 
chloroform regularly for every new attack during the course of a 
number of days in succession for that very purpose, with beneficial 
result. Bromoform was recommended by Stepp, in three or four daily 
doses of from one to four drops, to be given in sweetened water or 
in mucilage. 

Quinine has been used both internally and externally by a number 
of authors of good repute. It was first recommended by Binz. Ross- 
bach credits the drug with the power of relieving increased reflex 
irritability ; Binz, however, attributes to it an antizymotic action. He 
gives as many decigrammes daily as the child has years, so that a 
child of five years takes eight grains of quinine a day. He expects 
to find an improvement after two or three days, inasmuch as the 
attacks are said to become by that time shorter and less severe. 
When it cannot be given internally, he administers it in suppositories 
or in injections. When the sulphate or hydrochlorate is not tolerated, 
the neutral quinine tannate is selected instead, with this proviso, how- 
ever, that, the latter salt being much weaker than the former, it must 
be administered in doses from two to three times as large. It has the 
advantage of being tasteless. In our own country it is particularly 
Forchheimer who advocates quinine. He reported ninety-seven cases 
as having been benefited by its administration. Euquinine may take 
the place of quinine in the same doses. 

Antipyrin has been recommended for whooping-cough, since 1886, 
by Demuth, Sonnenberger, Moncorvo, Guaita, Wendt, and many 
others, as almost a specific. Like all the other chemical relatives of 
chinolin, it destroys parasites outside the organism. It has been 
claimed, or presumed, to display the same effect internally. Whether 
that is true remains to be seen. At all events, it is a powerful 
nervine. It is asserted that it can be given with the same bene- 
ficial result in the beginning of the disease and in its most severe 
stage, and that the latter will terminate favorably in from four to 
five weeks after the beginning of the treatment. The dose is from 
a grain and a half to two grains (0.1 to 0.125) three or four times a 
day for every year of the patient, with an occasional large dose for 
the night. 

Tussol, the amygdalate of antipyrin, is given in the same doses 
as antipyrin. As H. Rehn recommends it quite highly, it should be 
tried. It must not be given in milk, nor in close proximity to it. 



266 INFECTIOUS DISEASES 

Of all the almost countless medicines advised against whooping- 
cough I prize belladonna most highly. I have always returned to it 
since 1861, when I published my experience with it (Amer. Med. 
Monthly), after having discontinued it for the purpose of trying one 
after the other of the many remedies recommended during these forty- 
one years. 

The result obtained by me has generally been this : that a well- 
developed case of whooping-cough, after the diagnosis was made 
certain, would last for only three or five weeks longer, instead of 
running through its full course of months and quarters of a year. 
The effect is mostly not a sudden one. Many cases in which bella- 
donna is given from the commencement may become worse for a 
short time, then remain at their height for some days or a week, 
and gradually improve in both the character and frequency of the 
attacks. In others the effect is perceptible from the first days after 
its administration, the cases soon assuming a more favorable aspect. 

Infants of six or eight months of age affected with whooping- 
cough require a sixth of a grain (0.01) of either the root or the 
alcoholic extract three times a day ; children of three or four years 
tolerate three doses, each of half a grain (0.03). These doses appear 
to be very large in proportion to those tolerated by adults, but it is a 
fact which can easily be verified, that the effect of belladonna on the 
pupil and brain is hardly ever perceptible in children from these 
or smaller doses. The succession of belladonna symptoms in children 
differs, moreover, altogether from that in adults ; the erythematous 
and flushed appearance of the face and neck, sometimes even of the 
whole surface, is the first symptom in infantile age; whereas it is 
seldom observed in adults, or in cases of thorough poisoning only. 
Some of the old authors advised the administration of belladonna to 
such an extent as to produce the first symptoms of poisoning ; others, 
however, objected to this practice as dangerous. I, for my part, soon 
found that those children suffering from whooping-cough who exhib- 
ited general erythema from an apparent overdose recovered soon, 
while others, in whom no such symptom was observed, remained sick 
for a long time; and continued experience has proved that the 
occurrence of this symptom is absolutely necessary for the full reme- 
dial effect. To obtain control of whooping-cough, the remedy must 
be given in a dose sufficient to produce erythema, or at least a flushed 
condition of the face, and, as it were, feverish appearance after every 
dose of belladonna. Thus the dose is to be gradually increased until 
this result is obtained. It is a remarkable fact that very young in- 
fants may take proportionately large doses ; at all events, I do not 



WHOOPING-COUGH. BELLADONNA 267 

remember a single case in which less than half a grain was taken 
in the course of a day. The prescriptions I have been in the habit 
of ordering are very simple ones. I either give the medicament as a 
powder, or have the extract dissolved and sweetened according to 
circumstances, or give it as a powder mixed with sugar of milk. 

The administration of belladonna alone is indicated in such cases 
of whooping-cough as are not complicated with inflammatory affec- 
tions of the respiratory organs. The latter take the lead in compli- 
cated cases as well in treatment as in the nature and gravity of the 
symptoms. This is so certain that, whenever a pneumonia coincides 
with or follows whooping-cough, the peculiar sound of the cough 
of the latter will disappear, and return only when the inflammation 
begins to subside. As this is, moreover, the more dangerous of the 
two, it requires attention before the other. As to bronchial and 
laryngeal catarrh, the former especially is a very common symptom 
in whooping-cough. When it is slight, it may be considered as 
unimportant; when, however, it gives rise to fever or dyspnoea, it 
constitutes a further indication to interfere. 

The preparations mentioned above need not be the only ones to be 
relied on. The tincture of belladonna is a convenient remedy, inas- 
much as the dose can be readily and gradually increased. A baby 
of two years may take three daily doses, the first of which may be 
six drops. If the flush be perceptible within twenty or thirty minutes, 
that is the dose; if not, the number of drops must be increased to 
obtain the effect which is demanded after every dose. After a few 
days larger doses are required ; there is no case but demands at least 
twice the amount of the original dose of belladonna within ten or 
twelve days, or before the disease disappears. Atropine sulphate may 
take the place of belladonna. A child of two years will probably 
begin with the five-hundredth of a grain, to be given three times 
daily, and increased according to the rules stated above. 

Opium is spoken of favorably by a great many. I cannot recom- 
mend it for anything like regular administration, but it certainly has 
a good effect in procuring fair nights when given in a single dose. 
A grain of Dover's powder given to a child of two years, at bedtime, 
will, at all events, have the result of procuring sleep. In a number of 
cases the combination of opium and belladonna acts quite well. The 
antagonistic action claimed for these two drugs is not such as to 
interfere with their sedative properties. 

It is self -understood that the treatment is the same in those cases 
of pertussis in which the characteristic cough is less marked than 
attacks of sneezing or suffocation by spasm of the glottis. 



VI 

Diseases of the Nervous System 

I. General Indications. 

The great indication in the treatment of all diseases of the nervous 
system attended by symptoms of irritation is absolute protection 
against external disturbances. This is attained by equable climate, 
uniform temperature of the room, rest in bed, exclusion of light 
and noise, comfortably warm clothing, warm bathing, warm applica- 
tions and fomentations, and by the removal of anything and every- 
thing annoying and jarring. Therefore, children sick with nervous 
diseases must not be excited by unnecessary constraint or coercion, 
their medicines ought to be given in a palatable form, and vesicatories 
and other distressing applications avoided, if possible. Symptomatic 
treatment is perhaps more indicated than in the same class of ailments 
among adults. Pain and sleeplessness lead to speedy exhaustion. 
Nothing is more common and more dangerous than the prejudiced 
refusal to relieve pain by opiates and sleeplessness by properly selected 
hypnotics. It is particularly in those cases which are mostly, or 
entirely, of a reflex nature that a symptomatic treatment ought to 
accompany that of the causal indications. It is ludicrous as well as 
criminal to withhold chloroform when an eclamptic attack results 
from an intestinal irritation, or an antispasmodic when a cough is 
caused by stomach, ear, or nose. A convulsion may at any minute 
cause apoplexy, paralysis, idiocy, or epilepsy. 

Many symptoms may be relieved by the position of the head when 
they point either to hyperemia or to anaemia of the cranial contents. 
The former is benefited by a position approaching the vertical, the 
latter is relieved by a horizontal one. Not infrequently the former 
requires derivants (purgatives) and cold, the latter stimulants and 
warm applications. 

In conditions of depression, debility, and paralysis the treatment 
should be stimulant, exciting, and roborant. In such cases the elec- 
tric current is frequently employed, and is, to a certain extent, useful. 
Massage has a beneficial effect not only on the periphery, but by its 
general action on innervation and circulation, by its effect on the 
muscles, and also by its direct influence in increasing the relative cir- 
268 



ELECTRICITY. MASSAGE 269 

culation of the red blood-cells (John K. Mitchell).* Strychnine 
stimulates (while curare depresses) the reflex and vasomotor centres. 
Silver nitrate appears to exert a favorable influence in spinal paralysis ; 
muscarine, physostigmine, and nicotine in paralytic conditions of the 
unstriped muscular fibres. 

The interrupted electrical (faradic) current is an excitant — stimu- 
lant — of the nervous system, both locally and generally. For the 
latter effect general faradization has been practised, both through 
large electrodes and in the bath, to great advantage, according to 
many who have a right to claim a large experience. The generally 
stimulant effect does not. however, disprove the fact that, like the 
galvanic, the faradic bath is capable, particularly when the fine wire 
coil is used, of reducing undue sensitiveness. The action of the gal- 
vanic current is believed to show itself in different ways. It is stimu- 
lant and excitant, and (directly, or when interrupted by reversing), 
mainly when the brush is employed, produces pain, contraction, and 
consecutive dilatation of blood-vessels. It is electro-tonic, and thereby 
produces changes in the irritability of the tissues ; it is chemical, and 
thereby decomposes fluids ; and it is cataphoric, and thereby transfers 
solutions through badly conducting tissues. To the two poles differ- 
ent properties are attributed. It is the positive pole (anode) which is 
credited with a tranquillizing effect in inflammations and neuralgias 
(less in tic and hemicrania than in supraorbital, occipital, intercostal, 
lumbar, and sciatic neuralgias) ; the negative (cathode) is known 
to influence old inflammatory processes, cicatrices, and indurations. 
Still, there is no doubt in my mind as to the exaggerated character of 
the expectations once cherished in regard to the effects to be obtained 

* General massage (with dry hands) of the whole nude body, of extremities, 
neck, and trunk, lasting from fifteen to thirty minutes, is indicated in anaemia, 
chlorosis, tedious convalescence, chronic rheumatism, and neurasthenia. To 
reach the muscles some force should be used, but no violence, which is liable to 
cause capillary hemorrhages. Acute pain, local inflammations, and the presence 
of pus are contraindications. I have seen a good many cases of a chronic or 
an undiscovered peritonitis aggravated into an acute attack by reckless manipu- 
lation. Unless the physician has full control over the doings of a professional 
masseur and ample confidence in his skill, he should do the massage himself 
or employ a professional man who has selected massage as a specialty. The 
circulation of blood and lymph is best stimulated by massage of the whole length 
of the muscles. The lymph-ducts run along the intrafibrillar connective tissue. 
By compressing and emptying them and the blood-vessels from the peripheral 
ends in the direction of the centre of circulation a new supply is furnished and 
the general nutrition improved. Locally it acts well in recent injuries, contu- 
sions, and distortions, in subacute and chronic inflammations of joints, in neu- 
roses, contractures, arthritis deformans, and arthritic muscular atrophy (Hoffa). 



270 



DISEASES OF THE NERVOUS SYSTEM 



by both electricity and galvanism. The difficulty of reaching a cov- 
eted spot through tissues of different conducting powers is always 
great; the accumulation of fat is a powerful obstacle to the trans- 
mission of the current, and its amount cannot be calculated. This is 
so true that even for purposes of diagnosis the subcutaneous fat of 
babies and of many women offers a serious impediment. Besides, 
different morbid conditions and different periods of life interfere 
with the estimation of the effect of the current. In what has been 
called the reaction of degeneration both the faradic and the galvanic 
irritability of the nerves are diminished, and while the galvanic ex- 
citability of the muscles is preserved, the excitability by the faradic 
current is lowered. In the very young, — the baby under six weeks, — 
as general reflex irritability is quite low,* comparatively strong elec- 
trical influences are required to obtain effects. At all events, the 
action of the different currents is, to some extent, not measurable, 
controllable, or certain. The time during which both the faradic and 
the galvanic currents were considered far-reaching and omnipotent 
remedies has long gone by. Indeed, there are those, particularly 
among neurological specialists, who, while maintaining that the cur- 
rents are great aids for diagnostic purposes, yet reject their claims as 
curative agents. Years ago Meltzer — in a paper read before the 
Association of American Physicians — proved the total absence of effi- 
cacy on the part of the electrical current when applied to the mucous 
membrane of the stomach and the intestines. 

Franklinism, once the only recognized electrical remedy, has rap- 
idly regained a standing among electrical methods. But neither 
the common disruptive discharges used in locomotor ataxia nor W. J. 
Morton's " static induced currents," obtained by adding condensers 
to the static machine, will find many applications among children 
affected with diseases of the nervous system. 

The effect of the electrical and the galvanic currents is perhaps 
best exhibited in cases of peripheral nervous affections. Paralysis 
of the facial nerve and of the brachial plexus, both not infrequent 
after difficult or clumsy, rarely after easy, deliveries, when the female 
pelvis is narrow, the shoulders of the foetus large, or the head de- 
flected, are among those in which the current is frequently used ; its 
effect is mostly very slow, sometimes not very satisfactory. Par- 



* According to Soltmann and many followers, the irritability of peripheral 
nerves is small in the newly-born; it increases until he is six weeks old; at 
that time it equals that of the adult. The muscular reaction is slow, like that 
of a fatigued animal. 



AFFECTIONS OF NERVES AND MUSCLES 271 

ticularly in cases of facial paralysis in which the reaction of degenera- 
tion has already been established it leaves much to be desired. The 
paralysis of the brachial plexus of the newly-born, as it depends on 
stretching, laceration, or hemorrhage, and is sometimes complicated 
with injuries to one or more of the joints of the upper extremity, 
— in the lower joints the affection is rarely observed, — allows a 
doubtful prognosis only. It concerns mostly the fifth, sixth, and 
seventh lower cervical nerves, which form the posterior cords of 
the brachial plexus. In that case the deltoid, biceps, brachialis in- 
ternus, coracobrachialis, infraspinatus, and sometimes the exterior 
muscles of the hand are affected. When the lesion is deep-seated 
the whole extremity is paralyzed and will be shortened and atrophic. 
Some of the cases, however, are distinctly the results of an interstitial 
inflammation and consecutive hyperplasia of the connective tissue of 
the nerve-fibres. In such, no matter whether on the basis of syphilis 
or not, the interstitial hypertrophy should be fought with mercurials 
or iodides, or both. The same must be said of polyneuritis, — such as 
follows infectious diseases, with its pain and increasing paralysis and 
degeneration, together with intact bladder and pupils, — in which rest, 
sodium salicylate, and, later, arsenic and strychnine yield better results 
than does the current. Nor is it more effective in hemicrania, no 
matter whether it be the result of congenital disposition, or com- 
plicated with hysteria and epilepsy, or dependent on anaemia, hyper- 
metropia, dyspepsia, overwork, or confined air. In all these conditions 
the correction of the causes, a convex glass, country air, shortening 
of school hours, cold-water treatment, arsenic, iron, and aconitine, 
with an occasional dose of a bromide, will yield better results. 

To complete what I have to say on the subject of the remedial 
influence of electricity and galvanism, I may as well speak here of 
their employment in the peculiar changes of the muscles which are 
known under the headings of muscular atrophy, progressive juvenile 
muscular dystrophy, and pseudo-hypertrophy. All of these names 
are applied to abnormal conditions whose coarse anatomical changes 
are better understood than their causes. So long as these are un- 
known we cannot help admitting that therapeutical experiments, such 
as those with thymus gland in pseudo-hypertrophy, be they ever so 
tentative, are justified. In a certain percentage, indeed in the vast 
majority (exactly as in Thomsen's congenital myotonia), the altera- 
tion is in the beginning strictly local or confined to muscular tissue; 
in others there can hardly be a doubt as to the cerebral origin of the 
muscular anomaly. In all of them electricity and galvanism have 
been extensively used, together with massage, bathing, etc., but in 



2J2 DISEASES OF THE NERVOUS SYSTEM 

no case have their effects been noteworthy. The best results have 
been obtained through systematic exercise and training of the muscles. 
As in many other cases in which the original cause (or change?) is 
inflammatory, and exhibits itself in proliferation of cellular interstitial 
tissue (no matter what its final result is destined to be), mercury, 
mostly the bichloride, — administered patiently and watched carefully, 
— appears to have given me better results. At least, the progress 
seemed to be slower and intermissions of the morbid process more 
distinct and prolonged. 

2. Operations. 
Operations on the skull and brain are among the prides of modern 
operative surgery. Escapes from death on the table are more numer- 
ous than formerly, and recoveries from diseases formerly fatal, be- 
cause permitted to die without an operation, are not unheard of. 
Craniotomy has been performed for injuries, intra- and extra-dural 
hemorrhages, hydrocephalus, softening, tumors and cysts, Jacksonian 
epilepsy, athetosis, chronic contractures, certain mental diseases, other- 
wise incurable headaches, old cicatrices, and abscesses. Infants and 
children come in for their share, mainly with abscesses, hemorrhages, 
hydrocephalus, Jacksonian epilepsy, and premature ossification of the 
cranial bones and fontanelles, with epilepsy and idiocy among its 
results. So far as craniotomy and craniectomy are concerned in 
cases of microcephalics or idiocy, no other surgeon has met with the 
favorable results alleged to have been obtained by Lannelongue. 
Guided by thirty-three cases of American surgeons, — fourteen of 
which died soon, while nineteen only recovered from the operation, 
and very few showed any improvement, — I treated of the subject 
in my address before the Eleventh International Medical Congress at 
Rome, April, 1894,* and arrived at the following conclusions : that 
congenital idiocy is the result of many different forms of arrest of 
development (of blood-vessels, cortex, island of Reil, hemispheres), 
of inflammations (meninges, encephalon, with softening or sclerosis), 
of thrombosis, and of hemorrhage; that it is a frequent result of 
microcephalus, which, as a rule, is not dependent on premature ossi- 
fication of the bones and fontanelles, but in the large majority of 
cases on arrest of development of some parts of the brain, mostly con- 
nected with long-continued patency of the fontanelles ; that, there- 
fore, operations undertaken to widen the cranial cavity are of no 
use, for a brain which did not grow before the cranium closed will 

* " Non nocere," New York Medical Record, May 19, 1894. 



OPERATIONS ON NERVE-CENTRES 273 

not grow afterwards, and absent or defective parts will not develop ; 
that even cases with a clear history of premature ossification are not, 
or very doubtfully, benefited; that, finally, the operation undertaken 
for the purpose of enlarging the cranial cavity has the opposite effect, 
as is proved by the experience of Van der Veer and Hun, also by a 
case reported and drawn by Bourneville, and, finally, by the skull, 
belonging to B. Sachs, of a child operated upon twice in the course 
of sixty-seven days by A. Gerster. It exhibits a mass of hard tissue 
proliferating into the cranial cavity along the whole wound made 
in the first operation. I trust, therefore, that the days of uncalled-for 
craniotomy and craniectomy are numbered. Bourneville {Prog. 
Med., 1897, p. 390) favors craniectomy for idiocy in cases of trauma, 
abscess, or tumor only. W. W. Keen {Jour. Nervous and Mental Dis., 
February, 1898) reported eighteen cases of children, from twelve 
months to six and a half years old. Five died of the operation, six 
were slightly improved. His contraindications are : a fair-sized head, 
microcephalus, or age beyond seven years. 

Starr collected, in 1889, a total of 270 brain tumors in children. 
Of these 152 were tubercles, 37 gliomata, 34 sarcomata, 5 gliosarco- 
mata, 30 echinococci, cysticerci, and cysts, 10 carcinomata, and 2 gum- 
mata. The carcinomata were mostly secondary, the gliomata and 
sarcomata primary. Forty of the two hundred and seventy were 
superficial, and in sixteen of the forty their localities could be dis- 
tinctly diagnosticated. Therefore, trephining and operations on the 
substance of the brain for tumors will never be numerous. Their 
diagnosis is not always easily made, and that of the locality affected 
is beset, for the present, with still more difficulty. Gliomata are 
rarely near the surface ; solitary tubercles are sometimes found in 
the gray substance of the brain, but more frequently in the corpora 
striata or thalami optici. In many more instances an operation will 
be required because of tumors originating in the cranium or its peri- 
osteum and encroaching upon the brain; they are mostly sarcomata, 
fibro-sarcomata, or osteomata. One of the last mentioned I have 
removed. A cyst of the dura mater, resulting from hemorrhage, was 
successfully removed in the service of Dr. Henry Hun, at Albany, 
followed by marked improvement of the child's idiocy and convulsi- 
bility. 

Starr is rather favorably inclined towards trepanation in a num- 
ber of cerebral diseases ; it is true that those which promise no suc- 
cess from medical treatment cannot lose by surgical interference. In 
such cases of hemorrhage as permit of a localized diagnosis, though 
that between an extra- and an intradural situation may be impossible 

18 



274 DISEASES OF THE NERVOUS SYSTEM 

in many instances, he favors it. His advice of tentative interference 
with " microcephalics" I do not look upon favorably. Abscesses, 
unless they be the results of pulmonary gangrene, typhoid fever, or 
pyaemia, — if their location can be determined and is accessible, — 
are to be operated upon; the opening must be sufficiently large to 
permit of examination, and draining should be both extensive and 
prolonged until granulation and complete recovery take place. Tu- 
mors are not often the subjects of operation in children. It is true 
that many are met with in infancy and childhood ; according to 
Gowers, two-thirds of all the cases of intracranial tumors occur in 
the first two decades of life. But those occurring in early life are 
mostly found in the cerebellum, the basal ganglia, capsula interna, 
corpora quadrigemina, pedunculi, pons, and medulla oblongata, 
rarely in the fourth ventricle; very few such will ever be accessible 
to an operation. 

No case of obscure brain disease, and no suspicion of brain tumor, 
should be dismissed without the consideration of the possibility of 
its syphilitic origin. Gummata will occur, endarteritis is frequent. 
In these cases mercury and iodides, internally and subcutaneously, 
in ample doses, and continued a long time, are in order. Otherwise, 
nothing is left but symptomatic treatment : morphine, hyoscine, chloral, 
bromides, purgatives, hot foot-baths. Lumbar punctures appear to 
do no good; indeed, have done harm and resulted in sudden death 
when made in the presence of brain tumor. 

3. Inflammatory and Exudative Processes. Arrests of Development. 
The simplest form of cerebral meningitis is that which results from 
insolation and mental emotions and exertions. Frights (especially 
protracted fears) and overstudy are frequent causes. So is trauma, 
which, however, is liable to produce the purulent form. In pneu- 
monia, particularly of the upper lobes, it is not uncommon ; less fre- 
quent in typhoid fever, more so in the septic diseases of the newly- 
born, where, however, it is liable to form part of the general pysemic 
condition. With the exception of the latter, in which death is certain, 
an antiphlogistic course of treatment is indicated here, if anywhere. 
The hair should be cropped short ; the head must rest on a cool pillow 
and be placed high. Calomel at first in purgative, later in smaller 
doses. As the mercurial treatment is to be continued, a solution of 
potassic chlorate may be applied frequently to the gums and mouth. 
The heat of the head and the local inflammation must be fought by 
cautious cold applications, according to the directions given formerly 
(p. 94), and by leeches applied to the nasal septum or to the mas- 



VASCULAR DISTURBANCES 275 

toid processes, also by cupping to the neck and shoulders ; coma by 
cold affusions to the head and hot bathing, with or without mustard, 
of the rest of the body. Great restlessness, sleeplessness, and general 
excitability demand warm bathing, bromides in generous doses, from 
one to ten grammes (fifteen to one hundred and fifty grains) a day, 
chloral, and codeine. After the first invasion and the period of high 
fever have been successfully dealt with by calomel and a few large, 
afterwards moderate, doses of digitalis, the time for potassium iodide 
(from one to five grammes daily) has arrived, also for vesicatories 
to the neck and behind the ears. In regard to the latter, however, it is 
always well to be careful, for cantharides are the sworn enemies of 
the kidneys. The iodides must be continued a long time. Of the 
roborants to be given during convalescence, iron ought to be the last 
one selected. Lumbar puncture will be discussed shortly. 

It is not always easy to diagnosticate between a fully-developed 
meningitis and a hyperemia resulting from similar causes, — viz., 
overexertion, emotion, insolation, and the continued effect of over- 
heating and stimulating diet. The continuation of the treatment de- 
pends on the persistence of the symptoms. Quite frequently a warm 
or hot mustard-bath, with temporary applications of ice to the head, 
repeated hot foot-baths, sinapisms to the neck, an erect posture in 
bed, a calomel purgative (with or without local depletion), and occa- 
sional counter-irritation by derivant enemata (vinegar one, water five 
to six) will suffice. The passive hyperemia, however, complicated 
with and depending on general and local cerebral anosmia (occasionally 
even thrombosis of small vessels) and that which is caused by the 
rapid inanition produced by the different forms of acute and exhaust- 
ing intestinal discharges require an altogether different treatment. In 
place of the antiphlogistic treatment, stimulation is indicated. Still, 
caffeine and alcohol are to be avoided during the worst stage; cam- 
phor, ammonium carbonate, and musk will answer better. Food and 
medicines are to be regulated by the requirements of follicular or 
other enteritis, and water must be supplied in ample quantities. When, 
however, there is vomiting and when diarrhoea is persistent, neither 
the stomach nor the rectum will accept it. In these cases the only 
salvation may be in copious (pint or quart) subcutaneous infusions 
of warm and sterilized salt-water solution (water one thousand, table 
salt six to seven, with or without sodium carbonate ten to twelve). 

Thromboses from other causes are treated on the same principles. 
Debility and paralysis require such stimulants and irritants as the 
brain will tolerate. Embolisms, with their secondary conditions of 
irritation and inflammation, should be treated according to the rules 



276 DISEASES OF THE NERVOUS SYSTEM 

detailed above, and will require ice, purgatives, warm bathing, and 
iodides, with or without bromides. The resultant paralysis demands 
massage, electricity, strychnine, and mineral baths such as St. Cath- 
erine or Kreuznach. Chronic remnants of an inflammatory disorder, 
no matter from what cause, may be benefited, even after a long time, 
by a protracted course of treatment with potassium iodide, or with 
mercurials, or both together, or alternating. 

Ergot is useless in these cases of intracranial hyperemia; it 
does not have the favorable effect which often follows its use in simi- 
lar changes in the spinal canal. 

Polioencephalitis is either fcetal, or congenital, or postnatal. Its 
results are cysts, cicatrices, softening, atrophy, sclerosis, or poren- 
cephalia; its causes, sickness or syphilis of the pregnant mother; in 
the child, usually from one to four years old, syphilis or infectious 
diseases, such as influenza, measles, or scarlatina ; its symptoms, hemi- 
plegic (sometimes diplegic or paraplegic) paralysis with secondary 
contractures, more of the upper than the lower extremities, increased 
reflexes, and unilateral atrophy of the maxillae, forehead, or face. The 
acute attack requires rest, ice to the head, leeching, calomel, perhaps 
chloral hydrate and chloroform; the chronic condition, mercurials 
and iodides, massage, passive and active exercise, orthopaedic treat- 
ment, inclusive of tenotomy ; and those cases which result in idiocy or 
epilepsy, careful training and treatment in proper institutions. 

In connection with this spastic hemiplegia should be mentioned 
congenital spastic muscular contraction (Little's disease). It is the 
result either of a fcetal arrest of development or of inflammation, pos- 
sibly sometimes contracted during a protracted labor. The lower 
extremities suffer more than the upper, sometimes immediately after 
birth ; they rotate inward ; the body, hips, and knees are stiff ; the 
walk is equinus ; the sphincters always, intelligence sometimes, intact ; 
the muscles not hard during rest, but stiffened when being used. Im- 
provement is possible, but only with persistent and patient exercise 
and training and absorbent treatment. 

Tubercular meningitis is not always fatal, though the diagnosis 
permit of no doubt. The latter, however, is mostly made at an ad- 
vanced stage when the prognosis is already very ominous. Biedert 
had an opportunity to make an autopsy on a patient treated for tuber- 
cular meningitis, death resulting from another disease. He found old 
meningeal tubercles. Still, many of the recoveries reported — mainly 
for the purpose of proving the efficacy of specific treatments (tartar 
emetic and iodoform ointments and those more modern) — are of 
doubtful character. I have also seen recoveries from what I diag- 



POLIOENCEPHALITIS. TUBERCULAR MENINGITIS 277 

nosticated as tubercular meningitis. One died afterwards of necrosis 
of the cranial bones, occasioned by my tartar emetic ointment. 
Another case, that recovered thirty years ago, is still alive in an 
insane asylum; he has never been normal, mentally, since I dis- 
charged him " cured." From what little I have said it is evident 
that a preventive treatment only may be expected to do good, if any- 
thing will. Infants and children of scrofulous or tuberculous families 
should be brought up with unusual care, mainly when there was (or is) 
a case of tubercular meningitis in the family. Congestion of the brain, 
caused by feather pillows, exposure to the sun, hot rooms, coffee, tea, 
and alcohol, or physical and mental overexertion, must be guarded 
against. Trauma may become the proximate cause ; infectious fevers, 
such as measles, influenza, and pneumonia, also whooping-cough, 
require gr^at care. Constipation must be overcome. Eczema and 
other eruptions of the surface should be slowly healed, but they must 
be healed. Their presence is a constant source of danger, both by 
reason of the opportunities afforded for a direct invasion of microbes 
and of the irritation and swelling of neighboring lymph-bodies. These, 
when found, must be removed by internal treatment, massage, oint- 
ments (green soap, iodide-lanolin mixtures), or enucleation. Nasal 
catarrh should immediately be relieved ; adenoid growths in the naso- 
pharynx either regularly irrigated or, when they are large, removed. 
Their persistence is a cause of " scrofulous glands" and, possibly, 
of secondary tuberculosis ; also of direct invasion of germs through 
the patent orifices of the lymph-vessels at the base of the cranium 
and the extradural tissue. The best general preventive treatment 
of infants and children with a predisposition to tubercular meningitis, 
rendered probable by hereditary taint and by suspicious symptoms, 
consists, in my opinion, in the regulation of the diet and hygiene : 
animal food mostly, daily cool or cold bathing with vigorous friction, 
open windows, exercise, cod-liver oil during the cool and cold months, 
arsenic in regular small doses, and pure guaiacol (or guaiacol carbon- 
ate) f or many months in succession through a course of years, besides 
attention to the nares and adenoid growths. 

When the disease is fully recognized, constipation must be over- 
come; the first drug to be used for that purpose should be, or con- 
tain, calomel. It may be repeated from time to time, provided the 
regular use of potassium iodide does not contraindicate it for chemi- 
cal reasons. The latter ought to be given in large doses through 
(nearly) the whole duration of the illness. Tubercular meningitis 
both permits and demands large doses, — from one to three drachms 
(five to twelve grammes) daily. Mercury is indicated. Calomel and 



278 DISEASES OF THE NERVOUS SYSTEM 

potassium iodide being incompatible, the bichloride should be given, 
or mercurial ointments used instead. Cardiac stimulants may be 
employed to advantage from the beginning, the circulation being de- 
fective on account of the undue irritation of the pneumogastric nerve. 
Strophanthus (and strychnine in very small doses) appears to act 
better than digitalis. Caffeine and alcohol must be carefully avoided. 
Chloral will act well when headache is severe and a tendency to con- 
vulsions exhibits itself. To combat the latter the inhalation of chloro- 
form cannot be avoided; nor morphine altogether, when the pain is 
excessive. Antipyretics are not indicated in the beginning, when 
the temperature is low, except in the infant, with its tendency to high 
temperatures in the beginning; during the last few days, when, in 
the vast majority of cases occurring between the second and seventh 
years of life, it rises previous to death, they are useless. With tartar 
emetic ointments applied on the closely shaved head I have had ample 
experience, and shall not employ them again. My experience with 
iodoform ointments ( 1 to 5 or 10) is but small, and my confidence in 
their efficacy still smaller. Vesicatories may do harm by annoying 
and irritating the patients; I expect more derivative action from 
keeping the bowels open and the body sufficiently covered with cloth- 
ing. Leeches are seldom useful, except when conjunctival injection 
and local heat of the head become apparent at an early date. Other- 
wise, symptomatic treatment is all that can be advised. Unusually 
severe vomiting in the beginning may require ice pills and mild doses 
of an opiate, or cocaine, perhaps tincture of iodine in one-quarter- 
to one-half-drop doses, or arsenous acid, one-three-hundredth to 
one-five-hundredth grain (one-fifth to one-eighth milligramme), from 
four to ten times a day. Ice applications are useless, for the tem- 
perature is low before the last stage sets in, the local hyperemia mostly 
passive, and the tolerance of ice in small children easily exhausted. 

To what extent the operative treatment by trephining and drain- 
age will prove successful remains to be seen. There are but few 
cases of tubercular meningitis not complicated with general miliary 
tuberculosis ; thus the prognosis of operative interference is not at 
all promising. Besides, the cranial cannot be compared with the peri- 
toneal cavity, which is believed to be favorably influenced by the per- 
formance of a laparotomy. Peritoneal tuberculosis is very apt to be 
isolated and uncomplicated, its secreting surface of a different char- 
acter, and drainage easier. Still, trephining and drainage have been 
performed. Sins committed aseptically are readily forgiven. Since 
Quincke ( 1891 ) , lumbar puncture, mostly between the third and fourth 
lumbar vertebrae, has resulted in facilitating a diagnosis in many in- 



LUMBAR PUNCTURE. PARESIS 279 

stances and in temporarily relieving some symptoms, — those of con- 
gestion, oedema, pressure, coma, — but rarely aided in accomplishing 
a cure. 

In order to obtain any cerebro-spinal liquor from the cranial 
cavity, lumbar puncture should withdraw from ten to fifteen cubic 
centimetres. The total amount should not often exceed twenty or 
thirty at any one time. None may be obtained when the needle does 
not reach the spinal canal, or is obstructed by fibrin, or is caught 
between the nerve-fibres of the cauda equina, or when the connection 
between the ventricles and the cerebral and spinal subarachnoid spaces 
has been disturbed by exudative processes. The normal liquor, also 
that obtained in many pathological conditions, is clear, of 1007 specific 
gravity, and contains from 0.2 to 0.5 per mille albumin. One per mille 
albumin in the fluid means inflammation. Sugar is sometimes found 
in connection with tumors. In simple serous meningitis, in chronic 
hydrocephalus, in that connected with pneumonia and other infectious 
diseases, also with uncomplicated tumors, the liquor is clear, in 
cerebro-spinal meningitis it is turbid, somewhat purulent, and con- 
tains pneumococci and meningococci, in many cases (by no means 
all) of abscess and of cerebro-spinal meningitis pus and streptococci 
and staphylococci, in tubercular meningitis mostly bacilli, in apoplexies 
and hemorrhagic pachymeningitis blood. Kiliani and G. W. Jacoby 
found blood when the diagnosis of spinal hemorrhage had been made. 

Puncture, which should never amount to an aspiration because of 
the pain in back, head, and neck which is caused by it (Fiirb ringer), 
not always successful even as a means of diagnosis, has not yet given 
much satisfaction from the view of therapeutics. It gives some relief 
in meningitis, headaches (inclusive of the headache of chlorosis), 
delirium, and hyperesthesia, but these symptoms are liable to return. 
I am, however, so certain of having interrupted the course of cerebral 
inflammations and improved their sympoms temporarily, that I trust 
I shall see recoveries like those that have been obtained during the 
last few years. (Cerebro-spinal meningitis, Kohts, Netter.) In a 
few cases of cerebral lead symptoms, and in those connected with 
chlorosis, it is said to have given relief. Lenhartz improved a case 
of cerebral oedema connected with traumatic injury. H. Barth re- 
ported lately a case of tubercular meningitis (diagnosis by lumbar 
puncture) which recovered. The patient was two and three-quarters 
years old. Eight leeches in eight days. Altogether, it is to be hoped 
that we are standing in the vestibule of a new therapeutical achieve- 
ment. 

General paresis ("periencephalitis" and other changes; in a case 



280 DISEASES OF THE NERVOUS SYSTEM 

of John Thomson and D. A. Welsh — Br. Med. Jour., April I, 1899— 
atrophied frontal and parietal convolutions, patches of congestion 
and induration in the white substance, dilatation of the fourth ven- 
tricle, and granulating ependymitis of the lateral and fourth ventri- 
cles) forms no exception to the rule that the pathological changes 
occurring in the brains of adults are also found in children. Paresis 
is, however, rare. In a few cases there seemed to be an hereditary 
disposition as in other cerebral alterations leading to chronic intellec- 
tual disorders. The vast majority of cases are of syphilitic origin, 
and a thorough antisyphilitic treatment ought to result favorably now 
and then. 

The prognosis in, and the results of treatment of, chronic hydro- 
cephalus depend on its nature. When it is congenital, no matter 
whether internal or external, whether the result of a foetal inflamma- 
tion (of brain-substance, meninges, plexus, or ependyma of ventri- 
cles), or of obstruction by a tumor, or of an arrest of development, 
the morbid processes leading to it are so serious as to render the 
outcome of treatment — though it do not prove fatal — very problem- 
atic. Substantial changes of the original brain-substance cannot be 
remedied by the removal of fluid. Nor is it probable, or rather pos- 
sible, that the cerebral atrophy produced by permanent intracerebral 
pressure can be overcome by attempts at relieving hydrocephalus. 
The chances are better when chronic hydrocephalus is the result of 
a postnatal meningitis occurring after trauma, whooping-cough, or 
acute infections. But even in these cases, while the recoveries — I 
mean anatomical recoveries — from the secondary effusion are more 
numerous, the inflammatory alterations both in meninges and brain 
are such as either to predispose to future meningitis or to so alter 
both the physical and mental functions of the cranial contents as to 
render the result' either very doubtful or far from desirable. Our 
prisons and lunatic and idiot asylums tell the tales. The chances 
of hydrocephalic patients are best when the disease is the result of 
chronic hyperemia, — for instance, in craniotabes. Such children, 
with a slight amount of hydrocephalic effusion resulting from the 
hyperemia of rhachitis, are always apt to get entirely well under 
proper antirhachitical treatment (fresh air, animal food, phosphorus, 
iron, etc.), and even large amounts of fluids are absorbable, with 
restitution of the brain and its functions, in a certain percentage of 
cases. 

After all, it is evident that iodides, mercurials, vesicatories, dia- 
phoretics, diuretics, and purgatives are useless in congenital hydro- 
cephalus. In the other forms the diagnostic and therapeutical skill 



CHRONIC HYDROCEPHALUS 281 

of the practitioner will make the required selection, so far as indicated. 
Should the head grow rapidly, the prognosis is bad. In these cases 
even compression will do but little, inasmuch as compression of the 
increasing fluid, unless it can be removed, will also compress the 
brain. In less progressive cases the application of rubber bandages 
or caps, also adhesive straps round and over the shaved skull, may 
do some good. They should not be omitted in those cases which are 
being punctured, provided the cranium is still compressible. Indeed, 
in almost all the cases on which it was performed the children were 
quite young and no ossification of the sutures had taken place. There- 
fore, the case successfully operated upon by Rehn, of Frankfort, 
Germany (with repeated punctures), — that of a girl of twelve years, 
presented (alive) before the German Congress for Internal Medicine 
of 1886, — may be considered very exceptional. Cases which require 
trephining before drainage can be established hold out no hope, be- 
cause the skull and brain cannot close in upon the emptied cavity. 

Punctures of the hydrocephalic cranium were made in antiquity, 
but, like many other experiences of Hippocrates, were forgotten. It 
w T as not until this century that observations of recoveries were made 
after the intracranial fluids had found a spontaneous or traumatic 
outlet. Hofling published a case (1828) of recovery from hydro- 
cephalus after a complicated fracture of the frontal bones and a 
discharge extending over days ; Greatgood ( 1828) one after an injury 
produced by a nail; Haase (1818) one of spontaneous perforation. 
Huguenin collected six cases of recovery after a discharge through 
the nose (or ear) had been established. Punctures have been made 
in great numbers ; many more, certainly, than have reached the eyes 
of the medical public. It can, however, easily be understood that 
very probably not a single case of recovery has taken place that has 
not been published. Indeed, the publications were mostly made very 
soon — too soon — after the operation or operations were performed. 
Thus, when Beely collected twenty-seven cases of recovery after 
puncture (two of which were combined with tincture of iodine injec- 
tions), he expressly stated that only eight of them had been under 
observation a year or more. Altogether, it may be more human than, 
unfortunately, scientific to pride oneself on one's results, particularly 
when these results boast of benefit to mankind. Thus, Conquest 
reports " ten cures" out of nineteen cases operated upon by himself. 
Charles West, than whom there was no critic more learned, wise, and 
incorruptible, collected sixty-five cases with (alleged) " sixteen re- 
coveries," which he, however, reduced to three or perhaps five. Bat- 
tersby came to the conclusion that probably there was one recovery 



282 DISEASES OF THE NERVOUS SYSTEM 

in fourteen cases on which the operation was performed. But from 
my previous remarks, referring to the severity of the original lesion 
and to the results of the fluid present either outside or inside the 
brain, it is easily understood that I cannot look upon the result of 
the operation as anything like so favorable as is claimed. Still, there 
are many cases in which (when they are postnatal) it must not be 
omitted, together with general treatment. I have made a number 
of lumbar punctures for the same purpose, with visible effects on 
the distended fontanelles and sutures, but without a cure, and have 
come to the conclusion from a good many cases that if a puncture 
is to be made without the injection of iodine, the lumbar punc- 
ture should be preferred. It can be repeated as often as the cranial 
puncture, with very much less danger of consecutive oozing. Among 
the remedies I value most highly here, or wherever tissue-building 
is a main object, is phosphorus. It may be alternated or combined 
with iodides, digitalis, iron, or arsenic, according to circumstances ; 
also with antisyphilitic treatment in all cases in which, from com- 
plicating symptoms or the history of the father (or family), heredi- 
tary syphilis with its vascular degenerations can be presumed to be 
the cause of the hydrocephalic effusion. 

The cranial puncture should be made over the large fontanelle, 
about one centimetre or more (half an inch) from the median line; 
vertical when the lateral ventricle is to be reached, oblique when the 
hydrocephalus is external. It is best not to remove much fluid the 
first time: from twenty to twenty-five cubic centimetres (five to six 
drachms) will suffice. As a rule, there is but little reaction, and the 
operation may be repeated within a few days or a week. During 
the operation and after it compression must be made to prevent hyper- 
emia, hemorrhage, and rapid re-effusion. In cases of external hydro- 
cephalus a mild injection of iodine with potassium iodide and water 
("Lugol"), or Morton's fluid (consisting of iodine one part, potas- 
sium iodide three parts, glycerin forty-eight parts), may be made to 
suppress secretion. It will take very numerous observations, however, 
during many future years to determine to what extent all these at- 
tempts at suppressing secretion and at facilitating meningeal adhe- 
sions and reproduction of brain are to be considered valuable in the 
interest of families or of mankind in general. When the percentage 
of albumin contained in the aspirated fluid increases after every opera- 
tion, the prognosis is bad. 

N. M. Hunter, of Union Springs, Alabama, published in Pedi- 
atrics, August 15, 1902, the report of an operation on internal hydro- 
cephalus which proved successful and looks very promising. By 



BULBAR PARALYSIS. HERNIA 283 

the closing of the foramen of Magendie and all channels connecting 
the ventricles and the subarachnoid and subdural spaces, brought 
about by pressure from within and original lesions, the pia and dura 
were found dry. Now his operation consists in the introduction of one 
or more strands of fine catgut into each of the ventricles, landing 
them in the subdural space, and closing the dura and the external 
flaps. In this way the absorption of the fluid in the subdural sac and 
a complete recovery were accomplished. This operation will natu- 
rally be more appropriate and radically helpful whenever the brain 
has not suffered too much by pressure and atrophy. Postnatal hydro- 
cephalus offers a better prognosis than the fcetal form. 

A number of chronic degenerations of the brain, both general 
and local, are the result of inflammatory processes. If they be pre- 
natal, the prognosis is very bad; if acquired after birth, the nearer 
the beginning of the treatment to their starting the better the possible 
result. Such conditions are disseminated sclerosis, with its increasing 
bodily and mental failure, nystagmus, and death under the symptoms 
of deep sopor, also the congenital form of infantile spastic hemiplegia, 
Little's disease (p. 276), infantile spastic hemiplegia depending on 
polioencephalitis, and bulbar paralysis. The general indications for 
treatment are the same. In acute exacerbations, depletion, ice, and 
laxatives will be required. Bulbar paralysis, acute cases of which 
I have seen twice as the result of hemorrhage, with ptosis, accelerated 
pulse, rapidly increasing facial paralysis, also paralysis of extremities 
and of respiration, until death closed the scene within a day, may 
often demand a local application of ice to the nape of the neck. The 
chronic condition, with fibrillar twitchings, electrical changes, and 
absence of reflexes, requires the different forms of electrical and 
galvanic treatment, iodides, mercurials, and warm bathing. In all 
such cases the indications are pronounced enough, but the results 
mostly negative. It is only chronic cases that permit the treatment 
with iodides and mercury. Syphilis should never be lost sight of 
as a possible cause. 

Meningocele (a hernial sac with liquid contents only) and en- 
cephalocele (hernia of the brain-substance) are but rarely amenable 
to a successful treatment. When they are small, the protruding 
contents may be retained by a properly fitting appliance of lead or 
leather or rubber, until the abnormal aperture has had time to close. 
This process may be accelerated by the administration of phosphorus 
(ol. phosphoratum or elixir phosphori) in three daily doses of one- 
fourth of a milligramme each (one-three-hundredth grain). When 
larger and irreducible, the tumefaction has been caught in a clamp 



284 DISEASES OF THE NERVOUS SYSTEM 

and punctured, or removed altogether. In some cases the clamp was 
allowed to remain, in others it was removed; in the latter the wound 
was sutured. Modern surgical journals report favorable cases of 
operations performed not only on meningocele, but also on encephalo- 
cele. The complication with hydrocephalus impairs the prognosis. 
Similar treatment has been resorted to in a few cases of meningocele 
spuria, which results under an intact scalp from fissures of the cranium 
to which in infancy the dura mater is tightly adherent, induced by for- 
ceps operation, by fall or some other trauma, by caries, or by syphilis. 
There are complications of a grave nature. When the brain is 
injured down to a lateral ventricle the gap may become permanent 
and cause porencephalia. Rhachitis and the interposition of brain- 
substance between the fractured bone prevent spontaneous recovery. 
Indeed, it appears that the fracture never heals spontaneously; prac- 
tically, the fissure may close by the interposition of the thickened 
membranes and aponeurosis, together with diminution of the cerebro- 
spinal liquor. Such an apparent recovery may, however, not always 
be a blessing, for epilepsy and metastatic meningitis have been ob- 
served afterwards. Recent cases may be treated by the elevation 
of depressed bone and bone suture. In incipient spontaneous improve- 
ment (in fact, in stationary cases also) the tumefaction should be 
protected by a pad. Iodine injections have been made into the cavity, 
which contains cerebro-spinal liquor only, with occasional success ; 
and in a few cases of epilepsy and of rhachitical hydrocephalus, com- 
plicating the condition, the lateral ventricles were drained. 

4. Psychical Diseases. 
Psychical diseases have been believed to be rare in infants and 
children. The statistics published by lunatic asylums and by special- 
ists are meant to prove that. These statistics are correct, but the 
conclusions drawn from them are not. Every practitioner knows 
better. Suicide is on the increase. Dementia and mania are by ho 
means rare at any period of infancy and childhood ; melancholia, often 
without delusions and with suicidal tendency, and similar conditions 
of depression are not quite so frequent ; they are more generally found 
before and about puberty. The public institutions do not contain such 
patients. A perverse, demented, or even maniacal child is managed 
and prevented from doing harm to itself or to others, at home and by 
the family, better than an adult, and it is there that numbers of such 
patients can be observed. The same forms of mental disease occurring 
in the adult are seen in the young. Besides those which have been 
mentioned, we meet with moral insanity (often characterized merely 



PSYCHICAL DISEASES 285 

as motor and psychical restlessness, or incorrigible conduct), mono- 
mania, epileptic and circular dementia, even paresis and delirium 
tremens. More frequent than either or all of them are idiocy and 
cretinism, the former of which is a not rare termination of mental 
anomaly in the adult, while in the young it is among the first appear- 
ances of aberration, though, indeed, but the result of ever so many 
different anatomical changes. Here also heredity is one of the factors. 
A peculiar form of amaurotic family idiocy, almost exclusively ob- 
served in Hebrew families (thus far mostly Russian), always fatal, 
and associated with a characteristic condition of the macula lutea 
terminating in optic atrophy, with early blindness, was described by 
Tay and B. Sachs. Some varieties I have discussed above, also the 
possibilities of treating them medicinally or by surgical procedures 
(p. 2.72). Cretinism has some well-understood anatomical peculiari- 
ties or causes; prominent among them are the shortening of the 
cranial base by premature ossification of the occipito-sphenoidal syn- 
chondrosis and (it appears principally) the absence or degeneration of 
the thyroid gland. Thus, the cretinism of the foetus and infant and the 
myxoedema of the adult are among the results of the same anomaly. 

My object in enumerating most of the possible causes of mental 
disorders in the young is principally to show that the preventive treat- 
ment should be considered more reliable than the curative. Heredity 
plays an important role, so does inebriety and all other forms of 
psychical aberration or serious nervous disorders of parents ; for in- 
stance, epilepsy, diabetes. To what extent matrimony between rela- 
tives contributes to mental disease in the offspring is by no means 
proven. I cannot, from theoretical reasoning and from practical 
experience, admit that two healthy persons, be they ever so nearly 
related, will for that reason have a diseased child. But to what 
extent the state of the future will interfere with the marriages of 
insane and epileptic people, as also with those of carcinomatous or 
tuberculous patients, provided our therapeutics continues to be as 
unsatisfactory as hitherto, remains to be seen. It is natural, however, 
that the rapid favorable changes of the last few years in our thera- 
peutics, both internal and external, should increase our hopes in regard 
to great results. 

Diseases of the foetus, mostly of inflammatory character, — menin- 
gitis, encephalitis, chronic hydrocephalus, eclampsia, — predispose to 
mental disorders. So does syphilis of the brain. During birth, pro- 
longed labor or undue pressure by pelvis or forceps invites hemor- 
rhage with its results. Spontaneous hemorrhages are the more com- 
mon and the more dangerous the younger the infant. Congestions 



286 DISEASES OF THE NERVOUS SYSTEM 

and inflammation of the meninges or of the brain are frequent in the 
infant and child. Their causes are rhachitis of the cranium, insolation, 
hot stoves and bed-pillows, tumors, stimulants, such as coffee, tea, and 
alcohol, falls and blows, congenital or acquired diseases of the heart, 
and microbic infections. Disorders of the ears are frequent, and 
affections of the nose not unheard-of causes of intracranial disease. 
Infectious diseases, such as typhoid, scarlatina, erysipelas, rheuma- 
tism, influenza, are known to be direct causes of mental disturbance in 
the young. The removal of intestinal worms has ended a psychical 
disorder. I have known overexertion at school to result in mental 
aberration, which terminated either in recovery or in death from 
exhaustion or meningitis. The period of puberty, with its sudden 
changes, creates a predisposition, and excessive masturbation may 
cause derangement. Bad habits, bad training, and congenital migraine 
add oil to the fire. 

This cursory enumeration of causes gives plenty of food for 
thought. The conscientious family physician with a number of infants 
and children under his charge has a great responsibility. His cares 
ought to begin with conception. Many a case of infant meningitis 
(hydrocephalus) can be prevented by timely attention to the anaemic 
or syphilitic pregnant mother. Labor must not be permitted to last 
too long; asphyxia in the newly-born must be immediately attended 
to, and strict care should be taken of the diet and hygiene of the baby. 
Errors in this respect are not punished immediately ; and though some 
babies thrive, or appear to thrive, while mistakes are being constantly 
made, in others the foundations are being slowly laid for ill health and 
serious disease, both physical and mental. That heart and ears ought 
to be attended to in time, and persistently, is self-understood; but 
procrastination — waiting for better times and " second dentition" and 
" puberty" — is too common an occurrence. Perhaps the greatest 
negligence on the part of medical men is exhibited in regard to mental 
overwork. Our schools have become hot-houses in which scoliosis, 
near-sightedness, anaemia, neurasthenia, chlorosis, and cerebral exhaus- 
tion and disease are being bred in incredible numbers. If the children 
are sent to school at six or seven years of age, it should not be for- 
gotten that their brains cannot endure constant work without ex- 
haustion and injury. Between the sixth and ninth years persist- 
ent exertion, the teaching unit, should not last more than twenty 
or twenty-five minutes of every hour, between the ninth and twelfth 
years thirty or thirty-five, after the twelfth year forty minutes. For 
the first class two or three, for the second three or four, for the third 
four or five hours are all that should be enforced. Short learning units 



PSYCHICAL DISEASES. PAVOR NOCTURNUS 287 

permit earnest work and progress, long ones cause drudging labor and 
dangerous fatigue. The apparent offset to this mental overwork — gym- 
nastic or " calisthenic" exercise in the same building, as part of the 
curriculum — adds to the general exhaustion. It is time that the medical 
profession looked into the increasing degeneration of the people result- 
ing from this overstraining of the young brain, ninety per cent, of the 
growth of which is not attained until the seventh year, and the full 
growth not reached before the fourteenth or seventeenth. Physicians 
should no longer be afraid of the charge of going into politics. If 
they do not wish to be " politicians," let them be something better, 
— statesmen. 

The general remarks made on the first pages of this article will 
suffice for both the general and causal treatment. Serious and un- 
manageable cases belong to an institution. Conditions of excitement, 
besides proper hygienic and dietetic treatment, require rest in bed, 
warm bathing (not hot), and plenty of sleep, which may safely be 
procured by opiates (extractum opii, codeine), or hyoscine, chloral, 
sulphonal, amylene hydrate, notwithstanding the reports of individual 
cases of overdoses or idiosyncrasies. 

In the treatment of psychical disorders it is easy to do too little 
or too much. As long as our lunatic asylums are (were?) only more 
or less genteel prisons, and wherever the " superintendents" are custo- 
dians rather than physicians, where records are kept slovenly, and no 
autopsies made, nothing whatever is (was?) done to relieve the phys- 
ical basis of intellectual disorders. Whenever that is sought for, and 
found with more or less certainty, the indications for treatment are 
self-evident. Overdoing, however, is as bad as underdoing. Hyp- 
notism should not play a prominent part in the therapeutics of the ner- 
vous system. Its utility is doubtful and its dangers as great as those 
connected with all sorts of psychological experiments generally. 
Autosuggestion is very active in neurasthenic and hysterical persons, 
also in the young, who, when approaching puberty, even when in 
average health, are imaginative, unreasoning, credulous, and impul- 
sive (Hurd). 

Mild forms of temporary mental aberration are the night-terrors 
(pavor nocturnus) . They are mostly (not always) met with in deli- 
cate, pale, scrofulous, or rhachitical children, with neuropathic ten- 
dencies somewhere in the family. Like attacks of genuine dementia 
or mania, they are not remembered by the patients. But few of them 
are attended by fever ; many result from or are connected with diges- 
tive disorders, nasal polypi, adenoid growths, hypertrophied tonsils, 
and other causes of dyspnoea like asthma or rheumatic endocarditis. 



288 DISEASES OF THE NERVOUS SYSTEM 

These should be attended to. Heavy meals must be avoided, also emo- 
tions, frights, ghost-stories, and exciting games ; the attacks are often 
connected with reminiscences. The bowels should be kept relaxed. A 
dose of quinine or potassium bromide at bedtime and a well-aired and 
cool bedroom, not absolutely dark, are good preventives. 

5. Spinal Inflammations and Arrests of Development. 

The general rules for the treatment of diseases of the organs 
contained in the spinal canal are almost identical with those detailed 
in reference to the brain and meninges. With the exception of rare 
cases of pseudoplasm, the changes occurring in the spinal cord and its 
meninges depend on anomalies of the circulation, or on some form 
of inflammatory process, either in an acute or a chronic state. To the 
latter class belong the final and persistent lesions of spinal pachymenin- 
gitis and leptomeningitis, transverse myelitis, poliomyelitis, spastic spi- 
nal paralysis (the spinal form of what was described as cerebral spastic 
hemiplegia), lateral and amyotrophic lateral sclerosis, paramyoclonus, 
and tabes (hereditary or acquired). Multiple disseminated sclerosis, 
with its, at first, slight tremor in voluntary movements, which may be 
the only symptom for years, and is followed by nystagmus, optic 
atrophy, scanning speech, and tendon- jerks, appears to me mostly 
localized in the spinal cord in children. Before entering upon a course 
of treatment, it is of the greatest importance to study the etiology of 
an individual case ; a disease of the bone, or tuberculosis, or syphilis 
must be known before it can be effectually treated. The latter is very 
frequent, in the newly-born also, with supination of forearms or com- 
plete paralysis of one or both upper extremities or of the muscles of 
the neck. Nor is it superfluous to omit the exact diagnosis of those 
ailments which are at present supposed to be of an infectious na- 
ture and of bacteric origin, such as Landry's paralysis and poliomye- 
litis; for the time may come, even during our lives, when an exten- 
sive anti-infectious, antibacteric, antitoxic treatment or preventive 
immunization will be among the modern therapeutics of many appar- 
ently unmanageable diseases. Even acute myelitis, though many cases 
are directly connected (in the adult) with alcohol or tobacco, is cer- 
tainly dependent on gonorrhoea, syphilis, tuberculosis, and the acute 
(mostly streptococcic) diseases such as angina or influenza and 
typhoid fever. Some are hemorrhagic, with a tendency to spread 
upward or laterally. 

In every case of acute disease of the spinal cord or its meninges 
{hemorrhage, hypercemia, spinal meningitis) absolute rest is required. 
But the patient, to avoid overheating and hypostasis, must not be kept 



SPINAL INFLAMMATIONS 289 

on his back constantly or most of the time, and not on feather-beds or 
pillows. Quilts covered with linen or cotton sheets, air-mattresses, or 
water-beds are often absolute necessities. When the acute disease can 
be localized, as mostly it can, cold water, ice-water, the ice-bag, with 
now and then an ether spray, or local depletion by cups or leeches is 
indicated. Vesicatories or the tincture of iodine ought to be avoided 
in this stage because of their irritating and annoying effects. Purga- 
tives are required on general principles, — calomel (and) or salines. 
Now and then a mustard bath, quite hot, will act well as a derivant. 
The indications for digitalis (or other heart regulators and invigora- 
tors) are frequent; direct antipyretics are seldom required. Quinine 
acts better here than in diseases of the brain, in which it appears to 
give rise to occasional congestions. To influence the spinal circulation 
m acute and subacute diseases, ergot (useless in cerebral diseases) holds 
a high rank; the fluid extract may be given in doses amounting for 
the day to from one to eight or ten grammes in the beginning, later 
less, according to age. Its indication does not cease until the stage of 
chronicity, with anaemia, contraction, and incipient atrophy of the 
blood-vessels. Potassium iodide is indicated early on account of its 
influence on the circulation, and later for its absorbent effect. The 
difficulty in handling very old cases is due to the permanency of the 
local lesions which result from the solidification and cicatrization of the 
new cell proliferations. Nor are the difficulties in this respect any less, 
with the exception of some syphilitic cases, in regard to mercury. The 
sooner and the more persistently these remedies are employed, either 
internally or externally, either simultaneously or alternatively, the 
better will be their gradual effect. The bugbear of salivation is no 
longer feared since it has become more widely known that the younger 
the patient the better will he bear mercury. Galvanism and the electro- 
magnetic current are used on general principles, as mentioned above. 
Neither should be employed at an early stage. The former requires 
large electrodes, well salted, to reach the cord; the direction of the 
current does not appear to make much, if any, difference. Sessions 
of from six to ten minutes, the current being inverted once or twice 
during that time, once or twice daily, are all that is demanded. The 
interrupted current is employed later to stimulate the muscular action, 
and should be used locally with small or more generally with large 
electrodes, or in the bath. Anaesthesia may require the application 
of the metal brush. Warm bathing is often attended by very good 
effects, due to its influence on circulation and the surface temperature. 
A bath may last minutes or hours ; the latter mainly in secondary con- 
tractures, which may also require tenotomies. In these cases hot sand- 

19 



290 



DISEASES OF THE NERVOUS SYSTEM 



baths have been used extensively in Europe, particularly where the 
fear of water has not yet begun to wane from the minds of the masses. 
Their usefulness consists mainly in the invariability of their tempera- 
ture, which requires less attention and watching than a warm-water 
bath. In chronic cases ointments have been extensively used. Still, 
very few substances can be rubbed through the epidermis and cutis ; 
indeed, hardly any except potassium iodide (in glycerin, better still 
in lanolin) and mercury (ointment and oleate). Their application to 
the spinal column is of no advantage; it is better to select the usual 
places where the skin is thin and the lymphatics are near and numer- 
ous, — viz., the inner aspect of the extremities. Over the spine the 
actual cautery has also been found beneficial, together with the mineral 
springs containing salts and iodine (St. Catherine, Kreuznach, Oeyn- 
hausen, Nauheim). 

In many, both of the acute and the chronic cases, a symptomatic 
treatment cannot be avoided. Pain must be lulled. Now and then 
the anode (positive pole) of a mild galvanic current will have some 
such effect; sometimes the local application of chloroform ointments 
or chloroform vapor in cotton, an ether spray, a menthol stick, or men- 
thol in a ten-per-cent. alcoholic solution will do good. If not, hyo- 
scine, chloral hydrate, croton chloral hydrate, opiates (internally or 
subcutaneously), or hot fomentations are required; for there is no 
greater enemy of the sick than pain, and no greater bliss and gain than 
rest. Other symptomatic treatment may be required for the motory 
and trophic paralyses resulting from a number of spinal-cord diseases, 
such as paralysis of the bladder, of the intestines, of the sphincters, 
and bed-sores. The latter are very ominous, and the ointments of bis- 
muth, or tannin, or balsam of Peru, or fuchsin 1, lanolin 80, vaseline 
20, though they be indicated and locally useful, will not defer very 
long the final termination. Paralysis of the bladder is said to be 
benefited by local internal electrization ; it is benefited by ice-cold injec- 
tions ; its secondary cystitis is certainly improved by plain or medi- 
cated warm irrigation. Paralytic constipation requires physostigma, 
massage, and regular enemata. All of these forms of chronic paralysis 
will be more benefited by the subcutaneous than by the internal admin- 
istration of strychnine sulphate. 

Suspension has been practised for several years in some of the 
chronic diseases of the spinal cord, mainly in tabes, which, fortunately, 
is rare among children. That fad may again become fashionable in 
another generation. Operative stretching of nerves is occasionally 
useful in contractures depending on cicatrization, as also in some 
neuralgias of adults. 



TABES. POLIOMYELITIS 291 

While the symptoms of tabes dorsalis in children are rather identi- 
cal with those observed in the adult (ataxia appears late, often after 
disorders of the bladder, absence of patellar reflex, and paresthesia 
have existed for some time), hereditary ataxia (of Friedreich, a 
combined disease of the gray and white substances of the posterior 
and lateral cords) differs in this, that it may be seen in several mem- 
bers of the same family, has no defects of sensation, vision, and 
sphincters, and rarely of intelligence, and that ataxia of the lower and 
very soon afterwards of the upper extremities is an early symptom. 
Antisyphilitic treatment, galvanism, hydrotherapy, massage, and per- 
sistent active and passive exercise should be relied on. 

Acute poliomyelitis (spinal, essential, "dental" ( ! ), infantile 
paralysis), as the initial stage may differ both in its onset and in its 
symptoms, may require different measures at first. Some cases exhibit 
a high fever, great excitement and prostration, even cerebral symptoms. 
The majority, however, come on suddenly, without fever and with- 
out premonitory symptoms. These differences become explainable 
by the differences of etiological findings. The causative atrophy of 
the ganglia of the anterior horns is not primary, but in the first instance 
the result of vascular inflammation with proliferation of round cells 
and hemorrhages. All of these are, however, secondary and of an 
infectious nature like that of multiple neuritis. No specific bacteria 
have been found, but meningococcus and other cocci, a large spleen, 
hemorrhages on the pleura, swelled intestinal follicles and Peyer's 
plaques, proving infectious character, and complications with pneu- 
monia, enteritis, polyneuritis, rheumatism, endocarditis, abscess of the 
knee, and angina. W. Pasteur observed seven children in one family 
within ten days ; all of them had fever and headache, three paralytic 
symptoms, two transitory disturbances of nerve equilibrium, one 
typical poliomyelitis, one more cerebral, the others more peripheral 
symptoms, one angina. Endemics and epidemics have been described 
in fair numbers, leaving no doubt as to the infectious nature of the 
disease. According to Axel Johannessen (Festschrift in honor of 
Abraham Jacobi, 1900), Colmer (Amer. Jour. Med. Sci., 1843) re ~ 
ported a case of paralysis in a baby of one year which he observed 
in 1841 in the parish of West Feliciana, Louisiana. The parents told 
him of eight or ten other cases of the same disease that had occurred 
within a few miles during the last three or four months. The former 
class requires antipyretics and the necessary attention to cerebral and 
other urgent symptoms ; much more can hardly be done, because in 
most cases of this class the diagnosis will probably not be made at 
first, with the exception of those in which it is assured by local pain 



292 DISEASES OF THE NERVOUS SYSTEM 

and paralysis. These latter are the cases in which local applications 
of ice may prove beneficial. 

Every case, whether feverish or afebrile, requires absolute rest. 
The few which are suspected of originating in rheumatism, or those 
which are complicated with peripheral neuritis, should be treated by 
salicylates, and locally by warm applications or fomentations. All the 
rest will do better with cold applications — ice-water, ice-bag, cold 
water — continued for some time, but with interruptions. Depletion 
by means of leeches or by cupping is often indicated, particularly in 
such cases as exhibit local pain. I feel certain that a purgative in 
the beginning (calomel, salines) will do good; so will ergot; the 
equivalent of from one to three grammes or more may be given 
daily, either as extract of ergot or as fluid extract of ergot. It may 
be accompanied by a few drops of the tincture of belladonna. As 
early as possible — that is, as soon as the necessity of absolute rest will 
permit of inunctions being made — mercurial ointment (on the first 
day or days the oleate) may be used, and the internal administration 
of potassium iodide commenced at once. Both may be continued — 
particularly the latter — for several weeks ; the dose should be smaller 
than in cerebral meningitis, from half a gramme to one gramme daily 
being sufficient. Tincture of iodine modified by the addition of alco- 
hol, or sinapisms frequently applied for a few minutes at a time, may 
be used with advantage. 

The rapid improvement during the first w r eek after the onset of 
the disease, and the slow convalescence of the few months before the 
residual (mostly local) paralysis becomes final, having been estab- 
lished, the indications for treatment will change. Congestion and dila- 
tation of blood-vessels are followed by ansemia and contraction, and in 
place of belladonna and ergot, strychnine must be given; at first, per- 
haps, internally. It may be beneficial when so administered, but hypo- 
dermically it will act better. I cannot agree with Gowers, who asserts 
that it is probably " never either necessary or desirable to give it by 
hypodermic injection in this disease." On the contrary, many cases 
that had been treated with strychnine internally for months to no 
purpose gradually improved to a certain extent under daily, or three 
weekly, subcutaneous injections of from one to two milligrammes of 
strychnine sulphate. Still, a complete recovery I never saw. Several 
times a day, for weeks in succession, the cold shower-bath applied one 
or two minutes to the back, followed by lively friction, will contribute 
to the stimulation of the spinal circulation. 

The rapid waste of the paralyzed muscles requires local stimula- 
tion. Frictions with oil, vaseline, alcohol and water, tepid water, or hot 



POLIOMYELITIS. HYDRORRHACHIS 293 

water must be employed several times a day. When the surface circu- 
lation is still fair, cold water may be preferable. Passive movement 
must take the place of active exercise when the latter is impossible. 
The faradic current will stimulate and may improve whatever there 
is left of contractility. Should it become totally inactive, the reversed 
galvanic current may take its place for the purpose of exercising the 
muscles. Otherwise the galvanic continuous current is eminently the 
nerve and blood-vessel stimulant, and must be used daily to keep up 
the circulation and thereby the nutrition of the degenerating tissues. 
It is best applied through large electrodes, and should be made to 
ascend and descend alternatively. Sessions of from six to ten minutes, 
one or two every day, are sufficient, but they must be continued a long 
time. I know that limbs which had remained unchanged in their 
atrophy and uselessness for years improved under patient galvanic 
handling, when persisted in for a long time. 

Mechanical appliances will prove useful. The arm must be so 
supported as to render the slipping out of the socket of the paralyzed 
humerus an impossibility. The rare cases of dorsal paralysis re- 
quire a jacket or a properly fitting corset. The paralyzed (mostly 
extensor) muscles of the lower extremities demand elastic bands, so 
as to counteract the contraction of the antagonistic flexors and thus 
to facilitate walking. Meanwhile the remedial agents mentioned before 
must be continued. Strychnine will always do good, and phosphorus 
will act both as a nerve stimulant and as a tissue-builder. It may be 
given to a child a year old in doses of from half a milligramme (half 
a teaspoonful of the elixir of phosphorus of the United States Phar- 
macopoeia) to three-fourths of a milligramme daily. To expect an 
improvement of nutrition by ligating the paralyzed limb is a grave 
mistake. That procedure will tumefy, but not nourish, the constricted 
part. 

Consecutive club-foot requires the employment of proper ortho- 
paedic apparatuses at as early a time as is judicious, to prevent an 
unnecessary degree of anaemia, atrophy, and shortening. To avoid 
the necessity of such mechanical aids, operations are performed, 
which will be discussed in Chapter XIII. 

Circumcision has been performed on children affected with polio- 
myelitis, without any justification either in theory or in practice. 

The varieties of hydrorrhachis (spina bifida) depend on the more 
or less extensive arrests of development and their secondary changes. 
Like the differences between meningocele and encephalocele on the 
head of the newly-born, we must discriminate between a meningocele 
and a myelocele over the lower part of the nervous centre. The treat- 



294 



DISEASES OF THE NERVOUS SYSTEM 



ment, which should not be commenced until the diagnosis from 
dermoid or from teratoma is assured, differs accordingly. In more 
advanced years I have seen spinse bifidse, in the lumbar and in the 
cervical regions, whose connection with the spinal canal, originally 
narrow, was totally obstructed, so that their removal caused no diffi- 
culty whatever. Cases accompanied by malformations, contractures, 
or paralyses of the lower extremities do not respond favorably to treat- 
ment. Those rare ones which are complicated with superjacent tumors 
(mostly lipomata) or with hypertrichosis (very rare) must be care- 
fully watched, for careless operations on what was considered uncom- 
plicated pseudoplasms have proved fatal. Such as are of central 
origin, — myelocele, — in which accordingly the posterior columns with 
the nerve-roots spread over the interior of the sac, give a grave prog- 
nosis. Spontaneous bursting of the sac must be guarded against, for 
much loss of cerebro-spinal liquor is apt to terminate fatally in a very 
short time. Puncture may be resorted to and repeated, a fine needle 
being used. After each puncture pressure ought to be applied to pre- 
vent rapid filling up. A few cases — small ones of simple meningocele 
— have been known to get well in this way. Or, after the puncture, 
iodine may be injected. Morton's formula — iodine I part, potassic 
iodide 3 parts, and glycerin 48 parts — has been very felicitous in his 
hands and in mine. Favorable cases have been successfully treated 
by the clamp, suturing, and gentle compression, and bad cases by extir- 
pation of the sac and utilization of the periosteum of the patient. 
Robson transplanted that of a rabbit in 1883. Modern surgery has 
been fairly successful in a number of cases. Even paralysis was 
claimed to be no contraindication, for it was believed to be sometimes 
the result of pressure by liquid only. I never saw such a case. But as 
bad cases of spina bifida are sometimes complicated with other anatom- 
ical lesions, asymmetry of the body, stigmata of ears and teeth, 
besides the local hypertrichosis alluded to above, the difficulties grow 
in proportion. 

6. The Nerves. 
Neuritis may be communicated from inflammations of the neigh- 
boring tissues, but most cases occurring in infancy and childhood are 
the degenerative processes of peripheral nerves in infectious diseases, 
mostly in diphtheria, but also in scarlatina, typhoid, measles, etc. 
Polyneuritis itself sometimes assumes the character of an infectious 
fever, with enlarged spleen, nephritis, and high temperatures. Abso- 
lute rest in bed, warm fomentations and prolonged baths, sodium 
salicylate in daily doses of from ten to thirty grains (0.6 to 2.0), 
arsenic in different forms (Fowler's solution one to five drops daily), 



NEURITIS. NEUROMA. PARALYSIS. ECLAMPSIA 295 

antipyrin, chloral hydrate at bedtime, the galvanic current, and robo- 
rant diet without stimulants are indicated. Neuritis resulting in or 
complicated with cutaneous eruptions will be discussed in Chapter XL 

Neuromata (neuro-fibromata) are, it appears, always congenital, in 
many cases hereditary, mostly numerous, now and then painless, but 
sometimes very painful. They belong to the same class with cutane- 
ous fibromata, plexiform neuromata, certain forms of elephantiasis, 
and certain pigment nsevi. The treatment should be directed against 
the pain. The only radical cure is by extirpation (W. W. Keen and 
William G. Spiller in Festschrift). 

Peripheral paralysis is not infrequently noticed in a facial nerve, 
rarely from rheumatic or central causes ; often as the result of 
otitis, caries of the petrous bone, parotitis, or extensive lymphadenitis. 
The former requires sodium salicylate, antipyrin ; rarely pilocarpine, 
which is not well borne by the young, and should be given in emergen- 
cies only; the latter has a doubtful, sometimes a bad, prognosis, and 
requires the treatment of the cause. I once saw paralysis of the 
serratus muscle after a severe strain in whooping-cough, evidently 
the result of a lesion of the long thoracic nerve. 

7. Neuroses of Central or Local Origin. 
The treatment of eclampsia depends on its etiology. Repeated 
attacks may be the results of identical causes, — for instance, feverish- 
ness, intestinal disturbances, and emotions, — but they suggest the 
existence of epilepsy. Indeed, a single eclamptic attack cannot be dis- 
tinguished from an isolated epileptic seizure. According to the vari- 
ous causes to which eclamptic convulsions may be due, the best pre- 
ventives are regulation of the diet and of the bowels; the removal 
of worms and lice ; the withholding of alcohol, of the milk of an alco- 
holic mother, coffee, tea, and improper foods; and the watching of 
every kind of fever, from a simple catarrh to an inflammatory or 
infectious disease. In households where there are babies known to 
be subject to eclampsia the clinical thermometer is indispensable. 
Catarrhal fever, intermittent fever, pneumonia, otitis, meningitis, and 
acute eruptive diseases are often ushered in by a convulsion. Tight 
bandaging, renal calculus, and splinters in the skin are to be suspected 
when no other cause is readily found. A normal dentition never 
produces a convulsion, and " difficult dentition" as a cause of a con- 
vulsion is among the affections which are as rare as they are too 
readily diagnosticated.* The habit of lancing the gums (with its 

* See my Dentition and its Derangements, New York, 1862. 



296 DISEASES OF THE NERVOUS SYSTEM 

bad influence on gums and teeth, and the possibility of microbic 
invasion), to which many practitioners are still addicted, proves the 
frequent absence of diagnoses and the readiness with which tribute is 
paid to the prejudices of past centuries and to those of the female 
population. Cranial and encephalic rhachitis, with or without laryngis- 
mus stridulus, is often attended by convulsions, and requires anti- 
rhachitical treatment. 

The habit of regularly administering bromides to infants who 
have convulsions is a bad one. As a regular medication they ought 
to be reserved for epilepsy. The attack demands the removal of the 
cause. Irrigation of the stomach, or an emetic; irrigation of the 
bowels with water, soap and water, oil, turpentine, assafcetida ; a pur- 
gative (calomel with or without an antifermentative, such as resorcin 
or salol, followed or not by castor oil) ; the proper use of a warm bath ; 
a cold pack frequently repeated, with ice to the head and heat to the 
feet; the timely administration — in an urgent case antipyrin under 
the skin — of an antipyretic; chloral hydrate internally or by the rec- 
tum; inhalations of chloroform to shorten the attack, — all suggest 
themselves as most promising in certain cases. Chloroform ought 
not to be omitted, for at any moment a violent convulsion may occa- 
sion a cerebral hemorrhage with its dire effects on life, or body, or 
mind. Sinapisms to the neck and to the extremities have often been 
recommended, but, besides the possible after-effect of annoying and 
irritating the infant suffering from a vulnerable nervous system, they 
cannot be expected to have much or sufficient derivative action. To 
quiet the irritability persisting after an attack, chloral hydrate with or 
without a bromide, or repeated small doses of codeine or extract of 
opium, or the camphorated tincture of opium may be administered. 

The causes of chorea minor — St. Vitus's dance — are either anatom- 
ical changes (some of them improvable, some incurable) or func- 
tional disturbances ; perhaps also microbic toxins. Dubler and Meyer 
found a staphylococcus which Maragliano claims as pyogenes, Pianese 
a bacillus. That may explain its occurrence after scarlatina, measles, 
or influenza not complicated with rheumatism, and the frequent coinci- 
dence or complication of chorea with rheumatism. These two have 
often been taken to be coordinate effects of the same cause (toxic). 
This much is certain, that while rheumatic fever is often followed by 
chorea minor, the latter sometimes precedes the former by days. There- 
fore the treatment should vary according to the etiology, but hardly a 
case will do well without attention to the functional treatment. Indeed, 
some forms of the latter are almost of a specific character. Preven- 
tion is indicated when the patient is of a neurotic constitution ; the 



CHOREA MINOR 297 

descendant of a neurotic family; when suffering from digestive or 
genito-urinary disorders (masturbation) ; when accustomed to alco- 
hol in more than medicinal doses ; or when he has rheumatism or heart 
disease. Capillary embolisms and hemorrhages, cysts, tubercles, and 
exudative changes in the nerve-centres, particularly the brain, also in 
the anterior horns of the cord and the commissures, also in the white 
substance generally, are not subject to preventive measures. The same 
holds good in any cerebral lesion located near the pyramidal tracts, — 
viz., in the cortex, in the internal capsule, or in the basal ganglia. 
Demme observed a case depending on a fissure of the anus ; it admitted 
of direct treatment ; Soltmann a chorea of the left side after traumatic 
depression of the right parietal bone; others report cases depending 
on shrinking cicatrices and on neuritis. I have observed a marked 
case of acute chorea which was caused by spinal meningitis of the cer- 
vical portion. In this case ice, local depletion, purgatives, and ergot 
were the successful remedies. (Seguin's " Clinical Lectures," vol. i., 
1872, second lecture.) In the American Journal of the Medical Sci- 
ences, April, 1886, and in the " Festschrift zum 70sten Geburtstag von 
Professor Henoch," Berlin, 1890, I published observations of partly 
local, partly general chorea which depended on nasal reflexes due 
to catarrhal and inflammatory changes and to polypi. The symptoms 
were mainly facial grimaces, winking, drawing the mouth to one side, 
and shrugging the shoulders. They are identical with what has been 
described as " habit spasm" by Mitchell and Osier (4th ed., p. 1088), 
or " tic," the worst instances of which have been observed as peculiar 
forms of sudden muscular contractures, jumping, genuflexion, stoop- 
ing, etc. In all these cases the treatment and cure of diseases of the 
nose and nasopharyngeal cavity are demanded preliminarily to the 
successful treatment of St. Vitus's dance. 

When heart disease or a tendency to acute articular rheumatism 
is the cause, preventives share largely in the success of the treatment. 
The hygiene must be strict and medicinal attention to the cardiac 
ailment close. The rheumatic child must be anxiously watched; 
pain, be it ever so slight, requires rest in bed for one or two days 
at least and tentative doses of sodium salicylate. Helminthes must 
be expelled. 

Neurotic children, frequently with urine that contains phosphates 
in large quantities and has a specific gravity exhibiting the widest dif- 
ferences, should not be overworked ; the school sessions must be short. 
Cool or cold washes, with friction, and systematic, but simple and 
brief, gymnastics in the open air, not in a close school-room, will 
strengthen them. The period of convalescence from any incidental dis- 



298 DISEASES OF THE NERVOUS SYSTEM 

ease must be passed in bed, which should be placed, if possible, near 
an open window. Ansemia must be carefully watched and treated. 
The patient should not be allowed intercourse with neurotic, or hyster- 
ical, or choreic, or epileptic, or even merely violent children ; for some 
of the worst cases of chorea are those produced by fright. Headaches 
of a simply neuralgic or ocular origin must be attended to ; the latter 
usually require glasses, sometimes the protracted use of strychnine, 
but no misdirected and unauthorized operations when there is no 
disturbance of muscular accommodation ; in the former aconitine will 
often prove helpful. 

A patient sick with chorea minor must be kept quiet in body and 
mind, particularly when the case is a relapse, or caused by imitation. 
Bad cases will not get well, unless confined to bed in a quiet room, 
with no visitors or excitement, with but a single person present to 
entertain or read to them, with a warm, protracted bath daily, and 
with ample sleep. Very bad cases must be kept sleeping eighteen out 
of twenty-four hours by means of mild opiates or chloral hydrate with 
or without bromides. Sometimes large doses are necessary, but the 
effect must be obtained. I have met with cases in which an occa- 
sional inhalation of chloroform was also required. Meanwhile, the 
symptomatic measures adapted to the average case should be at- 
tended to. 

The best symptomatic remedy is arsenic, in the form of liquor 
potassii arsenitis or sodii arsenatis. Three doses are to be given daily, 
much diluted, after meals. When the eyes or the intestines begin to 
give trouble, or when a serious cutaneous eruption makes its appear- 
ance, or should the urine show albumin and casts, it is time to intermit. 
The doses must be increased slowly but persistently, according to the 
rule detailed on page 120. The original dose can be doubled or quad- 
rupled; indeed, can be increased almost indefinitely. The cause of 
failure on the part of arsenic is generally its insufficient dose. Mono- 
bromated camphor in daily doses of from four to ten grains (0.25 to 
0.6) will act well when arsenic cannot be, or is not, given. Aspirin 
appears to have good effects in three daily doses of from eight to 
fifteen grains (0.5 to 1.0), when given uninterruptedly for weeks, 
or with occasional interruptions. Antipyrin is successful in many 
cases. 

Of other remedies, silver nitrate may be mentioned; it is of 
less service here than in some other ailments of the nervous system. 
Zinc oxide or zinc valerianate may be tried, if arsenic happen 
to be omitted. The galvanic current, warmly recommended by Bene- 
dict, has not satisfied me. Sulphur bathing, either natural or artificial, 



CHOREA MINOR. TETANY 299 

is adapted to cases consequent on rheumatism ; it is indicated as 
after-treatment, as are also rational gymnastics and general robo- 
ration.* 

Tetany means tonic paroxysmal (for minutes or days) flexions 
of the carpal joint, the thumb turned into the hand, the fingers adja- 
cent to one another (obstetrical hand), also stiffness of neck, fre- 
quently equinus position of foot, with increased (motory and galvanic 
rather than sensitive and faradic) electrical irritability (Erb), with 
attacks caused by compression of vasomotor brachial plexus and below 
the knee (Trousseau), and mostly also spasm of upper lip and alse nasi 
through pressure below the zygomatic arch in front of the ramus 
mandibularis (Chvostek). It has been observed in different disturb- 
ances of the general health, after gastro-intestinal disorders and during 
the presence of worms, in convalescence from acute and chronic (par- 
ticularly infectious) diseases, after sudden exposures to changing 
temperatures, in chronic malaria, after injuries to the head, as the 
result of emotional irritation, or as a consequence of the abuse of alco- 
hol. The fact of the occurrence of tetany after total extirpation of 
the thyroid gland may lead in future to a correct diagnosis of many 
cases of tetany in children and to a regular, accurate examination of 
the thyroid gland. It is sometimes absent, or hypertrophied, or in 
an abnormal condition. The majority of cases are connected with 
rhachitis, mostly with its cranial (and encephalic) variety and its 
laryngismus stridulus. It is often found during cold springs, endem- 
ically, sometimes epidemically. The several causes enumerated above 
explain the occasional difficulty of a satisfactory etiological diagnosis, 
but suggest the preventive and curative treatment. Pilocarpine has 
been mentioned as the successful remedy in a case which was prob- 
ably caused by exposure. Gastro-intestinal disturbances (with or 
without autoinfection, accompanied by fever and by indican or 
acetone in the urine) demand proper medicinal and hygienic treatment, 
occasional purgatives, and intestinal antisepsis with resorcin, naph- 
talin, or salol. Tetany after infectious diseases and during con- 
valescence generally requires rest in bed, good air, copious (perhaps 
forcible) alimentation, and roborants. A very mild galvanic current, 
prolonged warm (not hot) bathing, bromides, chloral at night, and 
small doses of codeine in older children will be required according to 

* Huntingdon's chorea, a chronic meningo-encephalitis with atrophy of 
convolutions (first described in Philad. Rep., 1872) is an hereditary chronic 
progressive process not observed in children, which is liable to terminate in 
dementia after many years. It is characterized by incoordinate movements 
of the hands, face, and, gradually, also of the lower extremities. 



300 



DISEASES OF THE NERVOUS SYSTEM 



the severity of the cases ; they will get well after weeks or months. A 
roborant and antirhachitical treatment with cod-liver oil, iron, strych- 
nine in small doses, phosphorus, systematic exercise, and gentle hydro- 
therapeutic measures will restore the general health. The treatment 
with thyroid gland has not proved a great success in the average case.* 

Catalepsy is quite rare in children. I have seen but three well- 
marked cases, one of which, a boy of thirteen, landed finally in a luna- 
tic asylum. It is intimately related to hysteria and epilepsy, and often 
attended by psychical disorders. Both its prognosis and its treatment 
are dependent on the causes, among which fright, masturbation, chlo- 
rosis, malaria, helminthiasis, epilepsy, and melancholia have been 
enumerated. Thus, depletion, diaphoretics, emetics, nervines, anthel- 
mintics, and electricity have been recommended. In most cases medi- 
cines are less effective than is attention to general hygiene, both physi- 
cal and mental. In this respect it shares the fate and prognosis of 
hysteria, of which it may be considered one of the manifestations, the 
existence of which among children has been more extensively observed 
and studied since its nature, particularly in connection with mas- 
turbation, was discussed by me in 1875 (Amer. Jour. Obst. and Dis. 
of Women and Children). Hirschel and Fleisch observed catalepsy 
after intermittent fever, and Glas noted the case of a boy of five years 
who had an attack of catalepsy (instead of a chill), followed by per- 
spiration. In these cases quinine and arsenic take the place of other 
treatment, with better success. 

Another, though rare, symptom of hysteria is chorea major, 
which differs from chorea minor in the occasional appearance of 
paroxysms of coordinate spasms with psychopathic prodromi and (fre- 
quently) termination. Altogether, hysteria occurs with all the symp- 
toms met with in adults. It is not confined to the female sex in chil- 
dren any more than it is in adults, and exhibits the same debility and 
irritability of the nervous system in general and of emotions, reflexes, 
imaginations, and will in particular. Such children are by no means 
always anaemic. Hyperesthesia (more frequent than anaesthesia), 
paresthesia, localized paralysis (muscles of deglutition, first branch 



* Tetany should not be mistaken for a persistent muscular contracture of 
the extremities, mainly the distal ends, which may last many weeks and months. 
The latter has no interruptions, affects the thumb more than the fingers (with 
the characteristic (obstetrical) shape of tetany), appears mostly in the early 
weeks of life, has none of the facial symptoms of tetany, is not connected with 
rhachitis, and is not amenable to antirhachitical treatment. It depends some- 
times on intestinal disorders, but mostly on some affection of the central 
nervous system, and should be treated accordingly. 



CATALEPSY. CHOREA MAJOR. HYSTERIA. ATHETOSIS 301 

of facial nerve, ptosis), paraplegia, strabismus, spinal and other 
neuralgias, hoarse croupous cough and hiccough, general convul- 
sions, incoordinate choreic movements, tachycardia, and palpitations 
are among the symptoms. The lack of mental and emotional equilib- 
rium is an early feature. That is why it is found endemic in schools 
and other institutions; why also the original moral incompetency 
may (mainly about puberty) degenerate into moral insanity, neuras- 
thenia, melancholia, even mania. Vasomotor disturbances may cause 
"hysterical fever" with very high temperatures (from 105 ° to 108 
F.), which usually rise suddenly, last but a short time mostly, and, 
when attended by no proportionate increase of the pulse, betray 
their origin at once. It is found in psychopathic families as the result 
of mental strain, in badly ventilated schools, and depending on undue 
ambition, masturbation, diseases of the ovary, and emotions. Hysteria 
in a child means, unfortunately, in most cases, hysteria for life. Still, 
training and education are capable of accomplishing a great deal in 
strengthening will and character and independence of thought. Such 
children are better off among strangers than at home. School sessions 
ought to be regular but short ; work in the open air, housework, gym- 
nastics, and hydrotherapy, with general roborants, are indicated and 
prove successful. 

Athetosis, that peculiar form of localized (ends of upper extremi- 
ties mostly) pronating, supinating, flexing, and extending spasm, 
can hardly be improved when congenital. Now and then it accom- 
panies polioencephalitis or cerebral tumors or follows infectious fevers. 
Improvement is reported to have followed the use of arsenic, bro- 
mides, and galvanism. 

Most cases of epilepsy are observed in, or date from, infancy 
and childhood. In no disease is hereditary influence, not only direct 
but lateral, and that of other neuroses and of alcoholism more marked ; 
the state of the future will have to see to it that epileptic persons are 
not placed in a condition to raise progeny equally cursed. Epileptic 
mothers must not nurse their babies. The child known to be epileptic 
must be trained very carefully, both physically and mentally. Alco- 
hol and other stimulants, physical and mental exertions, and sudden 
emotions must be avoided. The hygiene of the skin and of the bowels 
requires particular care; the use of cold water (habitual washing 
and friction) is imperative; constipation must not be permitted. 
Feeding with gruesome nursery stories, tight dressing, and early 
schooling, also horseback exercise and swimming, are forbidden. In 
the interest both of the patient and of his schoolmates a public school 
should not be attended. The child ought to be instructed and trained 



302 



DISEASES OF THE NERVOUS SYSTEM 



with a view of preparing him for his future calling, which must not 
overstrain body or mind, must not be sedentary, nor should it confine 
him, if avoidable, to the limits and influences of city life and air. 

The diet must be non-stimulant in every way. Dark meats must 
be avoided conscientiously, white meats allowed in small quantities. 
Chlorides, including sodium chloride, have been advised against. It 
has even been proposed to bake bread with sodium bromide in place 
of the chloride, and to give eggs without salt. Milk, fruit, vegetables, 
eggs, and bread are appropriate. 

No case of epilepsy should remain without treatment. It is true 
that there are now and then spontaneous recoveries ; even hereditary 
cases may get better or well; remissions are frequent; intervening 
acute diseases and many operations have frequently a favorable effect. 
On the other hand, Gerhardt saw a relapse after an intermission of 
twenty years. But the knowledge of these facts must not tempt us 
to procrastinate medicinal and hygienic interference, or to hold out 
a hope of recovery at the period of " second dentition," of " puberty," 
or of " marriage." 

The best methods of treatment are always either specific or local. 
Symptomatic treatment may prove very successful with the aid of all- 
healing nature, but it is always a makeshift. The ideal indications for 
the cure of epilepsy ought to be — nay, must be — causal ; its proximate 
seat is in the cerebral cortex, but its actual origin in anatomical lesions, 
mostly, of different localities. Thus, epilepsy may be cerebral, it may 
be the result of persistently abnormal circulation, or it may be of a 
reflex nature. A (brachial) " Jacksonian" epilepsy cured by the re- 
moval of a foreign body from the ear was reported by Monflier. A 
few cases have been traced to nasal irritation and relieved by opera- 
tions on the nares. All sorts of cerebral tumors, solid or cystic, the 
results of previous encephalitis and meningitis from insolation, otitis, 
or otherwise ; arrests of cerebral development ; premature ossification 
of one, some, or all of the cranial sutures and fontanelles ; cerebral 
exhaustion from masturbation or premature venery; diseases of the 
heart with secondary venous obstruction; congestion from other 
causes (in a case of Gerhardt, enlargement of the thyroid) ; the 
influence of prolonged use of alcohol or ergot ; the sluggish brain 
circulation attending constipation and the general toxaemia of intestinal 
autoinfection ; external irritations such as tumors, cicatrices, foreign 
bodies, and the reflex excitement produced by carious teeth, Schneider- 
ian hypertrophy, and nasal and naso-pharyngeal growths ; vesical and 
renal calculi; helminthes, from taenia to oxyuris; in older children 
delayed menstruation, are so many different causes of epilepsy. It is. 



EPILEPSY. LOCAL TREATMENT 303 

therefore, only the most painstaking examination of all the organs 
and the whole surface of the body which gives a promise of finding 
the cause of the disease as well as the indications for rational causal 
treatment. 

Arrests of cerebral development are not amenable to treatment; 
the method of dealing with the chronic results of cerebral and menin- 
geal inflammations, also the possible value of operations on prema- 
turely ossified skulls, have been previously discussed. Most of the 
operations on the cranium undertaken for the purpose of healing 
epilepsy have not been successful, and the most enthusiastic promoters 
of such operations have rescinded their favorable opinions. Thus, 
the American Neurological Association, in a discussion which was 
mainly carried on by Sachs, Mills, Putnam, and P. C. Knapp, ex- 
pressed itself very reservedly on this topic. But there is no doubt 
as to an occasional success, nor can there be any as to the feasibility 
of removing tumors from the surface of the cortex, or of opening 
and removing cysts and the results of new or old hsematomata. 
B. Sachs and A. Gerster (Am. Jour. Med. Sci., October, 1896) came 
to the following conclusions. An operation is permissible in trau- 
matic epilepsy when the case is not over one or two years old. When 
there is a depression of bone, the operation is indicated at a later 
period, but should not be delayed. Trephining alone is sometimes 
sufficient. If the disease is of short duration, a part of the cortex 
may be excised. The complication with cerebral infantile paralysis, 
if the case be recent, is no contraindication to the operation. It 
must not be performed in epilepsy of long duration. Still, the human 
body not being a machine manufactured wholesale on a uniform last, 
and medicine not being mathematics, the indications both for medi- 
cal and surgical interference are neither geometrically exact nor are 
they gospel. For these reasons mistakes are always liable to occur. 
Jacksonian epilepsy will not always exhibit, at operations or at autop- 
sies, the local lesions boldly diagnosticated. Aye, recoveries may 
not be obtained, though no error be committed ; for, indeed, habitual 
convulsions may be so firmly established that even the removal of 
their original source is no longer an efficient cure. But the insuffi- 
ciency of medicinal treatment may be such as sometimes to necessitate 
or permit surgical interference as a possible last resort. Some sur- 
geons are very optimistic in regard to the operation mainly for Jack- 
sonian epilepsy. Braun (Deutsche Zeitsch. f. Chir., vol. xlviii., 1898) 
claims many recoveries or improvements; for instance, after the re- 
moval of bone splinters. " The operation should commence at the 
location of the injury ; if that be without a result, the motor centre, 



3 04 DISEASES OF THE NERVOUS SYSTEM 

the situation of which was first determined by the electrical current, 
should be removed to a depth of five millimetres. The operation may 
be performed after years have passed since the injury, though a 
shorter period is desirable." In non-traumatic Jacksonian epilepsy, 
however, Matthiolin reported 24.7 per cent, fatal cases in all opera- 
tions. Equally unfavorable is the opinion of Chipault, who saw no 
favorable results of trephining in the same class of cases. The causes 
of death after these operations have been recorded as follows : menin- 
gitis, sepsis, prolapse of brain, hemorrhage, escape of cerebro-spinal 
liquor, collapse, pneumonia, and pulmonary oedema. In connection 
with this subject I mention the resection of both cervical sympathetics 
and the upper and middle cervical ganglia. The verdict is : " not 
dangerous," but inefficient. 

It is particularly in cases produced by reflex from cicatrices and 
nasal irritation that local treatment, excision, cauterization, and the 
removal of polypi and adenoid growths have their signal, though 
rare, triumphs. The eyes have been accused — " eye-strain" — of pro- 
ducing epilepsy, and hence have been submitted to operations. My 
remarks on that subject, as connected with chorea, I can but repeat 
here. As regards local treatment, we have also to consider the effect 
on the genital organs when they are the cause of epilepsy. There 
is no doubt as to the occasional efficacy of digitalis, lupulin, or cam- 
phor in such cases. In others a chemical effect is aimed at ; thus, 
in epilepsy from chronic lead poisoning, sulphur baths and sulphur 
and potassium iodide internally have exhibited good results. 

If the approach of an attack be perceived, the patient ought to 
lie down on a low couch; the inhalation of amyl nitrite, if in time, 
has warded off many seizures ; its effect must not go beyond the 
first deep flush. If an aura rises from an extremity, a stout ligature 
around the limb may also act as a preventive, provided there is a 
palpable irritant — for instance, a scar — from which the irritation may 
arise. Otherwise it is very much more probable that the aura which 
precedes the attack is " a sensory manifestation of an irritation the 
focus of which is within the cranium, with no proof that the process 
is starting as a ' discharge' in the motor area, but rather is equally 
explicable as an intracranial excitation referred to the periphery in 
the same fashion that irritation of a sensory nerve anywhere along 
its course is also referred to its periphery" (William H. Thompson 
in Festschrift in honor of Abraham Jacobi). When the seizure can- 
not be prevented, it should not be interfered with; no hands must 
be forcibly opened, no convulsive jerking meddled with; but the 
patient must be protected against biting his tongue or otherwise hurt- 



EPILEPSY. MEDICINAL TREATMENT 305 

ing himself. Among the drugs recommended for epilepsy every nar- 
cotic and antispasmodic has had its day. Valerian, pseonia, and 
artemisia were once highly thought of; so was belladonna, and later 
atropine, with its paralyzing influence on blood-vessels. Curare was 
praised for its effect on the muscles. Copper sulphate has been recom- 
mended. Silver nitrate, in doses of not more than one or two centi- 
grammes daily (one-sixth or one-third grain), best in pills, may be 
continued, with intermissions, for a long time, and is credited with 
cures. It ought not, however, to be administered more than a month 
in succession, lest the skin show its effect. Twice in my life have I 
thus succeeded in producing argyria. Zinc has proved serviceable: 
the oxide, the valerianate (from twenty-five to fifty centigrammes 
daily), and the sulphate. The latter I have made much use of, be- 
ginning with three centigrammes (one-half grain) three times daily 
for an adult (a child in proportion), in increasing doses. Four 
grammes (one drachm) are dissolved in one pint of water, the first 
dose being a teaspoonful for an adult, ten or twenty drops for a 
child, the second the same dose plus one drop, the third the same 
dose plus two drops, and so on until after twenty days the double 
dose, after forty days the treble dose is reached. It takes a long 
time for tolerance to become exhausted; should this happen, a small 
reduction of the dose is all that is required. 

Kocher (Arch. kl. Chir., vol. lix.) observes that traumata, even 
without cicatrices and adhesions, cause epilepsy by mere increasing 
tension. That is why after trephining trie dura mater should be 
divided or a piece excised. Increased tension is a direct cause of 
epilepsy, whether congenital, or through inflammation, or tumor, or 
traumatic alteration. In fact, every disturbance of the circulation 
may cause epilepsy; therefore it may follow extensive defects in the 
cranium ; for " the intracranial circulation is arranged for a closed 
cranial capsule." Consequently, Kocher advises strongly to reduce 
the tension which causes or increases irritation by medication. 

To reduce the irritability of the cortex and the general convulsi- 
bility, and of the peripheral sensory apparatus, and thus in the course 
of time to cure epilepsy, the main reliance is on the bromides. I 
have not been able to convince myself of the injuriousness of the 
potassium salt. A belief in its harmful action has been the cause of 
the substitution of the sodium, or a mixture of the potassium, sodium, 
and ammonium salts. Whichever plan is followed, there are certain 
rules which are paramount. The remedy must be given for years ; 
it must not be interrupted unless there have been no seizures for years, 
except for very good reasons (excessive acne, paresis, sopor, head- 

20 



:;: DISEASES OF THE NERVOUS SYSTEM 

;.; ite ere perhaps the intervention ;: acute diseases T::e / r s j ^ must 

be surh,r£e:tt 2 child ;: rwc years may take three :r frur pra:u:::es 

forty-five ;r sixty prauts - res: :; g ■ : ■ pe :;fr 

at bedtime, perhaps half :: the daily amount: in this way the 

cerebri symptoms ;: averdosmg are oaost readily avoided. 

they irreir the else may be reduced but, except in rite insts 

dte retcted; shruld :::: be strrpei r:;:e:^: Perhaps die stron- 

v cake its place for a time, but I cannot 

say dcat e it leer has iritrressed me with the superiority which has 

imed f r them. The addition of modera: e loses ; : digi- 

• has efter irpearei :: me :; reduce the ;h: -.vsir.ess brcupht on 
notracted large doses. Arsenic in small but regular doses 
': ; ^::: the tendency :; icue 

I cann:: say that bromides are badly tolerated in the evening. 
rather the contrary: still, it is stated that they have a disagreeable 
effect In that case a sufficient Jose :f amylene hydrate or of chloral 
hydrate in produce slee? should take their place, Weber, of Dahl- 
::r: precedes ti= memide meatmen: wid: a regular : :.:•: :: amy- 
lene hydrate : on the other hand, there are those who condemn its 
7 altogether because ::' injurious effects which they say they have 
deserved Jasmovrim Jolly . 

FTechsig revmbines the sodium bromide treatment with that of 
erium His two or three daily doses of the litter, for adults, are from 
- 7 bo ten or twenty-five or thirty-five centigrammes each r.e- sixths 

; .:: grains). Larpe d:ses cannot, however, be given except in well- 
supemdse dens After six weeks : is suddenly discontinued 

and replied ~ 5 eprammes daily (two drachms) of the bromide. 
After this treatment has iter : :.tinued twe months the daily dose 
is rednced t t : grammes. Only when fright or other emotions 
7tT the proximal 7 ziuses the two remedies were combined early. 
FVrhsig predicts nc d:re:t effect preparatory action of 

the relate. Indeed, during the opium treatment there was no relief: 
but in combination with sodium bromide, cases which had lasted 
lee lie? ere improved. RaclclifTe. however ('according to Gowers. 
Lam::: 1880, [ —c found opium effective in some cases. Gowers 
saw but rarely any good effects from bromides and opium combined. 
but believes in tree usefulness of small subcutaneous doses of mor- 
phine when attacks reappear often and violently. He frequently com- 
bines brem;ee ; with derhalis Be:h:ere~ with iler.is lleeli :: rr.bir.es 
er alternates - - mrerire literal hydrate --as urpef by Seepum 
ir. enemata either by itself or in combination. The latest journal 
reports eu the FTechsig treatment are very contradictory. 



EPILEPSY. SALAAM SPASM 307 

From Charles A. Dana I learned the use of urethan, which was 
recommended by Demme in the eclampsia of children, in epilepsy. 
I have seen it stop epileptic convulsions (fifty every day, severe 
and mild) within a few days, not to return for more than half a 
year, when the child died from causes not connected with her epilepsy. 
The doses amounted to from two to three grammes (half a drachm 
to two scruples) a day, sometimes refracted; sometimes a large 
dose was given at bedtime. 

Pasteur observed that in a patient under treatment for hydro- 
phobia the epileptic attacks ceased (as they do cease after operations 
of any kind, strong emotions, or acute diseases). For this reason 
Charcot suggested systematic injections of rabic virus for the pur- 
pose of relieving or curing epilepsy. Gibier imitated the process and 
reported good results. Pierre Marie goes so far — a good deal too 
far — as to believe that " idiopathic epilepsy," which he asserts to be 
frequent, is of infectious origin in almost every case, is therefore 
preventable, and ought to be treated and cured with microbic toxin 
(Semaine Medicate, 1892, p. 283). 

The number of epileptics is so large, and the influence of the dis- 
ease upon the intellectual, moral, and physical condition of the indi- 
vidual, as well as upon the state and mankind, so wide-spread, as to 
be alarming. The subject has finally roused the anxiety of philan- 
thropists to a great extent. Country settlements of epileptics have 
been established in Europe, with beneficial results. As a result of 
combined efforts the following resolution was passed at a meeting 
of the American Neurological Association : 

" That it is the unanimous sense of the American Neurological 
Association that the proper care of the epileptic class, so long delayed, 
be urged upon the public, upon State authorities, and especially upon 
all interested in the care of the sick and defective poor, whereby 
they may be retired from asylums and almshouses, and may receive 
the required care in such separate establishments as their deplorable 
situations demand." 

The Craig Colony for Epileptics, at Sonyea, in Livingston County, 
New York, has published its eighth annual report. The world is 
moving. 

Salaam spasm (spasmus nutans), a peculiar affection of muscles 
of the neck, either the sterno-cleido-mastoid and trapezius, which are 
controlled by the accessory nerve, or the rectus anterior capitis, longus 
colli, and the scaleni. Bad cases may show contraction of the levator 
anguli scapulae, deltoid, biceps, and diaphragm, also the glottis. 
Nystagmus, noticed when there are cortical disturbances which may 



3 o8 DISEASES OF THE NERVOUS SYSTEM 

lead to epilepsy, must receive the treatment proper for its causes. 
As a predisposing cause rhachitis is pre-eminent. Perhaps the en- 
cephalic changes of rhachitis are in many instances the main cause of 
the spasm. The age of the patients (from four to twelve months) 
is still the age of unsteady eyes and waggling movements of the 
head. Insufficient light in the dwelling gives rise to eye-strain and 
consequent exhaustion of the cerebral centres. The spasm often sets 
in during the weakness of convalescence and nearly always during 
the excitable period of teething. There was also sometimes the his- 
tory of a blow on the head, which means a fright (John Thomson 
in Festschrift in honor of A. Jacobi, 1900). In some cases there were 
intestinal disorders. 

Rotatory spasms, combined or not with squinting, nystagmus, and 
mental disturbances, saltatory, sneezing, yawning, snapping, spitting, 
hissing spasms, should be treated according to their origin. Most 
of them are symptoms of hysteria. Many of the patients are thor- 
oughly anaemic. There are indications for potassium bromide, the 
positive pole of the galvanic current upon the convulsive muscle 
(sterno-cleido-mastoid (or) and trapezius), also massage and anti- 
rhachitical treatment ; besides the closest attention to diet and 
hygiene. 

Stammering is pre-eminently a disease of the nervous system, and 
is probably caused by a diseased condition or insufficient tone of the 
cerebral cortex, with lack of equilibrium, exhibited in some by choleric 
temperament, in others by cowardice, together with disturbance of 
will-power and an absence of coordination of respiration and the 
muscles of the larynx and mouth. In some it is the result of nervous 
talkativeness, fidgetiness, and flightiness on the part of parents or 
attendants ; in some of imitation not checked at the proper time. 
Strengthening of mind and body is the main indication. Training, 
cold water, and exercise will fortify the character; bromides may 
for a time relieve irritability. Coordination of innervation and muscle 
may be achieved by loud and slow speaking and by reading, reciting, 
and singing. Self-confidence must be encouraged in every way. 
Among strangers and in institutions established for the purpose, with 
good air and food, and plenty of exercise with forcible excursions 
of the diaphragm, such patients are mostly benefited, not infrequently 
in a short time. Local affections of the respiratory tract must be 
attended to, adenoid vegetations of the naso-pharynx removed, and 
other anomalies of the nares, provided they interfere with respiration, 
corrected. 



VII 

Diseases of the Digestive Organs 

A. The Mouth. 
i. Fr cerium of the Upper Lip. 
The upper lip is retracted and remains short, and the mouth is 
kept open when the frcenum of the upper lip is short and hard. It 
should be incised and loosened. 

2. Harelip and Fissure of the Palate. 

Harelip should undergo an operation, unless there be a strong con- 
traindication, on the first day, or at all events early in life. The diffi- 
culty of nursing is, in part, obviated by the successful closure of the 
cleft in the upper lip, and the sooner the deformity is removed the 
better are the chances for a correct position of the future teeth, for 
articulation, and for the shaping of the upper lip and nose. 

Fissure of the palate requires an erect posture* during feeding. 
A plastic operation to close a fissure of the palate is indicated when 
the alveolar processes are not too steep and the tissues sufficiently 
normal and copious to permit a complete occlusion. At the same 
time the patient should enjoy general good health and be intelligent 
enough to aid in the operation. Before the sixth or seventh year 
of life the latter cannot be expected. The early periods of infancy 
are not favorable times for the operation, but a vital indication is 
furnished by the necessity of sufficient feeding and the danger of 
bronchitis and pneumonia resulting from the easy access of cold or 
contaminated air. If the operation can be performed before the child 
speaks, the prognosis in regard to articulation is very much better. 
Still, insufficient strength, whooping-cough, bronchitis, etc., are 
powerful contraindications. 

3. Tumors in the Oral Cavity. 
An adenoma of the parotid was noticed in a nursling by Eros. 
Fibroma occurs in the periosteum, enchondroma and osteoma in the 
lower jaw, sarcoma (epulis) in the alveolar process, where it mostly 
originates in the periosteum. They should be removed soon. The 
first (of the very few cases on record) congenital sarcoma of the 
tongue I reported in 1869 (Journ. Obst. and Dis. of Women and 

309 



3 io DISEASES OF THE DIGESTIVE ORGANS 

Children) . It was removed by the galvano-cautery. Biedert (" Lehrb. 
d. Kind.," nth ed., 1894, p. 168) reports the case of a girl of ten years 
with sarcoma, which commenced in a tonsil and extended over all 
the neighboring organs. When she seemed to be almost moribund 
she was taken with erysipelas and got well. The report was made 
eight years after her recovery, which took place with considerable 
cicatrization. The case holds out great hopes for Coley's treatment 
of sarcoma by means of the serum prepared from the streptococcus 
of erysipelas and the bacillus prodigiosus. 

4. Ranula. 

The sublingual glands are sometimes seen as gentle elevations 
when the tongue is normally raised. Some acini of one or both 
glands, however, may undergo cystic degeneration and form cysts 
of any size up to that of a pigeon's egg. The same sort of cystic 
tumors are formed in the obstructed Rivinian duct and in the lymph- 
ducts between the genio-hyoid muscles, very rarely in the ductus 
lingualis or its ramifications. When they impede nursing, deglutition, 
or respiration, they should be removed. As the walls are very thin 
(mostly), enucleation is not practicable; the simple incision is rather 
useless because it will soon close up; the introduction of a silk- 
thread seton may favor suppuration and sepsis ; the removal of a fairly 
large part of the visible wall, which is then turned in and sutured, 
with subsequent application of carbolic acid or of the silver nitrate 
stick (with immediate application of salt solution afterwards), gives 
the best results. Cysts formed by congenital obstruction of the 
Whartonian duct should not be called ranula. Dermoids and degen- 
erations of the submaxillary glands, also lymphangiomata, are met 
with that should not be mistaken for ranula. 

Concretions in the efferent ducts of the sublingual and the sub- 
maxillary glands can usually be expelled by gentle pressure. If not, 
a short incision will free them. 

5. Milia. Epithelial Pearls. 
Along and near the raphe of the palate of the newly-born and 
nursling there are (sometimes numerous) hard, yellowish-white con- 
glomerates of small size. Now and then they rise above the level 
of the surface. They are usually (not cystic, not comedones) accu- 
mulations of epithelia in the small vacuoles of the mucous membrane. 
Mostly they disappear spontaneously ; sometimes, under the influence 
of injury and microbes, they ulcerate. Pus is occasionally seen. I 
have observed perforations of the palate. In that condition they are 



TUMORS. RANULA. MILIA. STOMATITIS 311 

sensitive or painful, interfere with nursing and nutrition, and are the 
starting-points of thrush or of still more serious infectious diseases. 
Then, but then only, a daily application of a solution of silver nitrate 
(1 to 50 or 500), mild when only the surface is ulcerating, and fre- 
quent brushing (not rubbing) with a solution of potassium chlorate or 
of sodium biborate (1 to 30 or 40) will be all that is required. 

The perforation alluded to is very exceptional. Syphilitic and 
diphtheritic (rare) perforations furnish their own indications both 
for local and general treatment. 

6. Stomatitis. 

The catarrhal form, mostly with inflammation of the gums {gingi- 
vitis), results from uncleanliness (retention of food in the mouth), 
from constant sucking on fingers and nipples, or is observed in con- 
nection with nasal catarrh, glossitis, pharyngitis, gastro-enteritis, peri- 
tonitis, or the exanthematic acute eruptions. This mild form demands 
cleanliness, drinking of cool water (mainly after every feeding), 
cooler temperature of the food, unless it be breast-milk, and wash- 
ing either with potassium chlorate or borax solutions. In those cases 
in which the mucous membranes and the tongue are dry, a solution 
of silver nitrate ( 1 to 500 or 2000) should be brushed on once a day. 

The follicular form, in which vesicles are found over the mucous 
membranes, tongue, and pharynx (not the gums), with a tendency 
to rupture, is very painful, is often attended by high temperatures, 
and interferes with swallowing; it should be treated, besides locally, 
with potassium chlorate, eight grains (0.5) in five ounces (150.0) 
of water and glycerin (10 or 15 to 1), a teaspoonful to be taken every 
half-hour, and no water to be given immediately after, so as to secure 
the local with the general effect. 

The ulcerous variety (stomacace) originates in the gums of chil- 
dren between two and eight years of age. It affects the lower (more 
frequently than the upper) incisors and canines on injured epithelium, 
after careless cleansing and washing, sucking of soiled fingers (cocci, 
etc.), and the milk of cows affected with foot-and-mouth disease. 
Friihwald claims to have found a bacillus not met with in the healthy 
mouth, also cocci ; Bernheim, a bacillus and a spirochete. The tissue 
becomes hypersemic, bluish, and undergoes a rapid parenchymatous 
disintegration, looks white, is soft, breaks down, loosens the teeth, and 
attacks the adjoining angle of the mouth and cheeks, which undergo 
the same destruction. There are copious salivation, offensive odor, 
and sometimes extensive necrosis of bones. As it is mainly observed 
after measles (most frequently) or pneumonia and infectious diseases 



312 



DISEASES OF THE DIGESTIVE ORGANS 



generally, often in rhachitical and scrofulous children, and in nurseries 
and foundling asylums of the old (?) style, feeding (which is often 
resisted), tonics, and stimulants are urgently indicated. Internally, 
potassium chlorate as in the follicular form, in doses not larger, but 
more frequent. Most cases do not require anything besides, with 
the exception, perhaps, of the local application, a few times a day, 
of potassium permanganate solutions (i to 250 or 500) or of an 
attenuated tincture of iodine. Bad cases terminate in extensive de- 
struction of an angle of the mouth and adjoining cheek. Secondary 
noma is rare. 

The aphthous variety, with yellowish or gray spherical and flat 
fibrinous deposits between the epithelium and the tissue of the mucous 
membrane, sometimes complicated with small hemorrhages, may be- 
come dangerous when grave, and may interfere with swallowing. 
When there is a tendency to superficial ulceration, silver nitrate in 
water (1 to 50) may be gently applied once daily. Other treatment 
has been outlined above. Chronic neurotic stomatitis will be discussed 
m Chapter XL 

Hemorrhagic stomatitis is observed in scurvy, in diphtheria, and 
in other infectious diseases ; the diphtheritic form in diphtheria ; the 
syphilitic, with its circumscribed whitish or grayish condylomata and 
other symptoms, in nose, larynx, skin, or bones, in syphilis. The 
treatment of these local manifestations has been discussed in other 
chapters. Mercurial stomatitis is rarely seen in infants and children, 
the less so the younger they are. When it does occur, potassium 
chlorate internally, in small and frequent doses, and as a mouth-wash 
(1 to 30), is as good a curative as it is a preventive. 

All of these forms of stomatitis have a marked influence on the 
lymph-bodies of the neighborhood, mostly below the lower jaw, 
but also those of the cheek. These are located on the lower jaw, 
on the upper jaw, behind the angle of the lower jaw, and near the 
orifice of the Stenonian duct. As a rule, their tumefaction will dis- 
appear with the reduction of the symptoms of the stomatitis which 
caused them. 

7. " Bednar's Aphtha" 

They are not aphthae, but flat and more or less extensive ulcera- 
tions, resulting from atrophy of and injury to the epithelium and 
mucous membrane of the alveolar processes and the palate of the 
very young (first month), also around the epithelial pearls near the 
raphe. In the newly-born a moderate physiological desquamation 
takes place on all the integuments, both skin and muous membranes. 
Thus, normally, the epithelium is thrown off. The oral mucous mem- 



BEDNAR'S APHTHAE. THRUSH 



313 



brane is very thin, over the posterior alveolar process it is very tense, 
and mostly so about the insertion of the pterygo-mandibular liga- 
ment. There, while the mouth of the newly-born is kept open, the 
mucous membrane becomes quite pale. A slight stomatitis, a mod- 
erate ill-nutrition, and careless and rough handling of the mouth 
of the baby cause abrasions and ulcerations, which may be quite 
small or extend over square inches. They are dangerous to the same 
degree as they interfere with nursing or feeding and facilitate the 
invasion of microbes, which are numerous, but accidental, either 
saprophytes or pathogenic. These may cause an infectious disease. 
Thrush is a frequent sequela. The above etiological remarks preach 
the sermon of prevention. Look after your nurses, their finger-nails, 
and the material they shove into, the babies' mouths. Silver nitrate 
(1 to 250 or 1000) in one daily application, and gentle brushing with 
boracic acid (1 to 30 or 50), or with sodium biborate, will mostly suf- 
fice. If a stronger disinfectant be required, potassium permanganate 
(1 to 200 or 500) is preferable. Much crying on the part of the 
baby is injurious by the stretching of the mucous membrane of the 
posterior lower alveolar processes. After each meal a few teaspoon- 
fuls of water should be given to clear the mouth of food remnants. 

8. Thrush. 
Membranous stomatitis is very frequent and popularly known as 
thrush (muguet). The postnatal desquamation of the epithelium, 
the open mouth which allows the constant passage of air and mi- 
crobes, the narrow nares which add to that predisposition, uncleanli- 
ness, retention of food in the mouth, excess of sugar in the food, and 
previous pneumonia or infectious disease, which adds to the hypersemia 
of the oral cavity, facilitates the deposit of oidium (no healthy epithe- 
lium permits it), which, with streptococci and staphylococci, detritus, 
a little fibrin, and foreign remnants, form deposits, granulations, 
and membranes mainly on surfaces covered with pavement epithelium 
(mouth, tonsils). Oidium is also found in the intertrigo of the nates, 
occasionally even in the cranial cavity; its gonidia are met with in 
the gastro-intestinal tract, where they cause gastritis and enteritis, 
atrophy, and possibly death. It is therefore necessary to treat thrush 
early. The membranes can almost always be scraped off easily. A 
solution of boric acid (three or four per cent.), of sodium biborate 
(two or three per cent.), or of potassium permanganate (one-half to 
one per cent.) should be applied five or six times daily. A daily appli- 
cation of silver nitrate ( 1 to 500) is useful after the membranes have 
been removed. Internally, as gastro-intestinal complications are fre- 



3H 



DISEASES OF THE DIGESTIVE ORGANS 



quent, resorcin and bismuth may be administered (bismuth subcar- 
bonate one gramme = grs. 15, resorcin twenty-five to forty centi- 
grammes = grs. 4 to 6, water fifty grammes, glycerin ten, a 
teaspoon ful every two hours). 

9. Noma. 
Phlegmonous gangrene of the cheek, sometimes originating in the 
gums, is commonly known as noma. It is of unknown cause (neuro- 
pathic, microbic, thrombotic?) ; at all events, no bacillus has as yet 
been identified as its cause or regular attendant, with the exception of 
the endemic described by G. Bloomer and A. Macfarlane in the Amer. 
Journ. Med. Sci., November, 1901. Leptothrix was found in each of 
their sixteen cases (mouth, vulva, rectum, alone or in combination). 
As isolation stopped it, contagion is probable (by soap? towels?). The 
worst complication was pneumonia, the best remedy the thermo-cau- 
tery. It is mostly observed after measles, typhoid fever, scarlatina, or 
other infectious diseases, or after reckless mercurialization. The same 
process, under the same circumstances, may be observed about the 
vulva, anus, and other parts. It never occurs in the healthy child. 
During the process the blood-vessels, nerves, and Stenonian duct may 
take part in the disintegration, or remain intact; when the blood is 
not coagulated in the vessels, a case may die, while apparently getting 
better, of a hemorrhage which in the septic condition of the patient 
need not be large. The mortality is high, more than seventy-five 
per cent. The hard, black node grows fast, the fearfully fetid ulcera- 
tion destroys soft parts, teeth, bones, and finally life, unless the process 
be stopped. The actual cautery (electro-, thermo-cautery) employed 
once or more is most effective, also fuming nitric or sulphuric acid, 
or a ten-per-cent. solution of zinc chloride; when it has stopped, 
potassium permanganate (1 to 100) or the dioxide may be applied, 
or tincture of iodine, or formalin (1 to 15 or 30). The strongest 
stimulants in large doses — alcoholic beverages, musk, and strychnine 
— should be given. As it is mostly seen after infectious diseases, etc., 
we should learn the lesson of not relying too much on the lazy nihilism 
of thoughtless " expectant" methods. 

10. Sublingual Adenitis. 
The inflammation of the sublingual gland (sometimes connected 
with parotitis) is mostly seen in the puerperal infections of the newly- 
born, but also in after-years. It may heal, but requires early incision 
to relieve the pus, and frequent disinfection with potassium perman- 
ganate (1 to 200 or 500 water). The abscess may become very large 



NOMA. SUBLINGUAL ADENITIS. PAROTITIS. DENTITION 315 

if the surrounding cellular tissue participates in the suppuration. The 
incision should be large, and disinfection very careful. 

11. Parotitis. 
The endemic and epidemic varieties were treated of on page 220. 
If the Stenonian duct be obstructed by simple or mercurial or ulcerous 
stomatitis, or by diphtheritic deposits, the gland will swell and become 
inflamed. Cold applications, gentle massage with green soap, or with 
a potassium iodide lanolin ointment, will succeed, unless there be 
suppuration. In this case an incision is required. A metastatic form 
of parotitis, with numerous cocci in the pus, may be observed in 
variola, typhoid fever, scarlatina, and anaemia. Warm fomentations, 
large incision, and thorough disinfection are demanded. 

12. Difficult Dentition. 
Dentition is a physiological process ; before a tooth protrudes the 
gums above it are slowly absorbed so as to show a slight depression, 
with no hypersemia. Some time previously the gums are raised and 
more or less hyperaemic. The only perceptible symptom is the eager- 
ness of the baby to bite. Increased salivation has nothing to do with 
dentition, but with the increased function of the salivary glands, 
which, like the growth of the teeth, of the head, and of the brain, 
is the result of the physiological hypersemia of that part of the body 
connected with the large size of the carotid arteries. When the gums 
are abnormal, hard, tense, perhaps under the influence of a stomatitis, 
there may be a slight fever, hot head, sleeplessness which is improved 
by taking the baby up (head elevated), even some muscular twitch- 
ing; for at that time of life excitability is great and inhibition in- 
sufficient. Diarrhoea is not a result of the normal teething process. 
This extends over the foetal and infant periods ; what is often called 
so is only its termination. One or two decigrammes of a bromide 
may be given (one and one-half or three grains) once or often, and 
the mouth should be washed with cool water. The long period of 
dentition is also the time of many disorders and diseases, which 
are not always easily diagnosticated and may tempt the practitioner 
to suggest or accept the diagnosis of difficult teething. Lancing 
the gums, which, with calomel, used to be the every-day treatment 
of infants at the time of teething, has lost most of its charms. There 
are, fortunately, practitioners who prefer making a diagnosis of the 
real condition of the ailing baby, and that and its improvement or 
cure comprise the main treatment I recommend for " difficult denti- 
tion." 



316 DISEASES OF THE DIGESTIVE ORGANS 

Great care, however, should be taken of the teeth. They should be 
washed after every meal and rubbed off. Caries grows very rapidly ; 
the loss of a tooth results in narrowing the place for the permanent 
tooth that is to follow, perhaps after years only ; extraction should be 
resorted to only for painful pulpitis or for purulent osteo-periostitis. 
In rare cases a temporary tooth should be removed when it prevents 
the permanent from protruding. 

13. Dental Ulceration. Riga's Disease. 
When there are but two lower incisors, and they the only teeth 
present, the tongue is irritated by contact and friction; that is, as is 
readily understood, particularly frequent in whooping-cough. In this 
way the dental ulceration is caused. When the irritation lasts long, 
and results in a secondary inflammation with hyperplasia of the tissue, 
the tongue adjoining the frenulum is not only discolored, grayish, 
and slightly granulating, but exhibits a slight excrescence, with a 
somewhat irregular surface and of marked density. Fibroma has 
been met with. That is what is called Riga's disease by Fede and 
Concetti, who say it is very rare in Rome, but very common and often 
grave in some parts of Southern Italy. Infants with vulnerable 
tissues are most apt to be affected ; moreover, the sore surface, being 
very much exposed, may become a breeding-place for pathogenic 
microbes and their toxins; diphtheria, sepsis, cachexia are thus en- 
gendered. The name is an unnecessary addition to our nomenclature. 
According to the condition of the surface, it may be moistened fre- 
quently with a solution of potassium chlorate, or of borax, or of 
potassium permanganate, or of the dioxide, or be cauterized with the 
solid stick of silver nitrate once every two days, or the actual cautery. 
The ulceration or tumor is almost certain to disappear when a few 
more teeth make their appearance in the lower jaw. Mild cases may 
get well without any treatment. Bad cases will improve with recovery 
from accompanying atrophy or cachexia. 

B. The Tongue. 
I. Congenital Anomalies. 
They are more or less amenable to surgical treatment. The bifid 
tongue (arrest of development, consisting in the non- juncture of the 
two halves of the first branchial arch) may thus be improved. I re- 
moved a sarcoma with the galvanto-cautery (p. 309). Lipoma is 
mostly located on the tip of the tongue; is quite small, or reaches 
the size of a hen's egg ; is sometimes pedunculated, and interferes with 



ANOMALIES AND INFLAMMATION OF THE TONGUE 317 

nursing and nutrition. It should be extirpated, as also dermoids and 
cystic hygromata. The latter may also be injected with an irritant 
fluid (Lugol's solution, alcohol) ; lymphangioma may be punctured 
with the actual cautery in different places. The latter is one of the 
forms of macro glossia; its other variety is muscular; it is mainly 
this latter which enlarges the tongue in every direction, makes it 
protrude and excoriate, and dislodges the teeth. It has been reduced 
by the ecraseur and by ignipuncture. A wedge-shaped piece may be 
excised and the flaps joined. Hypertrophy of the tongue accompany- 
ing any of the varieties of cretinism requires the prolonged use of 
thyroid. Adhesion of the tongue to the floor of the mouth (ankylo- 
glossia), when in the rare form of extensive epithelial cohesion, is 
easily relieved by gentle traction, or separated by means of a blunt 
probe; when caused by the shortness and extensive insertion of the 
frsenum, it requires an incision by scissors. It is better to make a 
superficial incision only than to cause a hemorrhage which is stopped 
with difficulty. The affection does not interfere with nursing, so that 
the little operation is not urgent. A further contraindication to making 
a long incision into the frsenum is the possibility of rendering the 
tongue too movable, and thus facilitating aspiration of the tongue, 
which may prove fatal. In that condition the lower lip is drawn 
in and the tongue backward so as to prevent respiration. In a few 
cases it was observed in whooping-cough and laryngospasm ; in the 
majority its original cause was obstruction of the nose by coryza, or 
congenital narrowness of the nostrils, or a swelled floor of the mouth. 
Insufficient innervation of the tongue has also been charged with 
occasioning its aspiration. The treatment of the difficulty depends on 
its etiology. 

2. Glossitis. 
Superficial changes of the tongue (erythema, catarrh) participate 
frequently in the same alterations of stomatitis, pharyngitis, infectious 
diseases, and digestive disorders. The latter do not influence the 
tongue, however, so much as they do in adults. These superficial 
alterations require no treatment. Very little, if any, is required in 
the peculiar changes of the epithelium, which is thrown off in the 
shape of smaller or larger islands and accumulated so as to form 
whitish and elevated edges round the bare spots (geographical 
tongue). It is only bad cases that require treatment. Lactic acid 
in solution has been recommended. I prefer silver nitrate once 
daily (1 to 500). A similar solution (1 to 1000) I recommend on 
the smooth red tongue with or without fissures; it is mainly the 
latter which should be touched by the medicine. A mouth-wash of 



3 i8 DISEASES OF THE DIGESTIVE ORGANS 

potassium chlorate and the internal administration of the same are 
beneficial in all of these conditions, alone or in combination with the 
above; also in most ulcerations, those caused by carious teeth, or in 
the attacks of epilepsy. The ulcerations caused by overdoses of 
mercury and accompanying gingivitis and salivation require frequent 
and small doses of potassium chlorate ; for a child of two years one 
gramme (fifteen grains) daily. The acute inflammation of the tongue 
(acute glossitis), however, should not have to wait for the slow effect 
of any treatment. Its rapid swelling and intense redness, with a 
tendency to suppuration, demand a deep and long incision rather than 
a mere scarification of the surface. 



C. The Throat, 
i. Pharyngitis , including Amygdalitis (Tonsillitis), Hemorrhage. 
It is met with in many varieties, — catarrhal, phlegmonous, erysipe- 
latous, lacunar, follicular, and parenchymatous. All the diseases of 
the mouth may descend into the pharynx. The catarrhal inflamma- 
tion of the pharynx is, however, apt to be more serious ; fever, dys- 
phagia, even convulsions, are noticed, besides annoying or dangerous 
complications with nasal diseases. Exposure, dry (furnace) air, or 
exertion (screaming) may bring it on. Nasal irrigations of warm 
(90 F.) saline solution relieve the naso-pharynx and the pharynx of 
accumulations of mucus. Gargles are not so reliable (p. j6) as appli- 
cations of ice-cloths or of ice-bags, potassium chlorate as advised 
above, with small doses of tincture of belladonna, also an astringent 
spray for docile older children. Tonsils, when acutely swollen, are 
relieved by a scarification made at an early period. In that way 
chronicity may be avoided, with its constant liability to admit microbic 
infection and to cause the development of adenoid vegetations. The 
lacunae (crypts) of the tonsils, as they do not recede into the ton- 
sillar tissue, but are mere surface depressions, are the seat of a 
superficial process partly parasitic and partly irritative. Lacunar 
amygdalitis is rare in infants, more common later; its fever is high 
or not ; glandular swellings of the neighborhood are quite com- 
mon (Koplik in Festschrift). The deposits — sometimes large enough 
to form membranes — are made up of epithelium, erythrocytes, leu- 
cocytes, detritus, bacilli, and cocci, or, instead of the latter, in rare 
cases, leptothrix. This latter form was first described by B. Fraenkel 
in 1873 and Emil Gruening in 1882, and lately by Alois Epstein 
(Festschrift, 1900), who gives the interesting history of the affection 
(Gruening is not mentioned). It is not at all a disease of adults, as 



PHARYNGITIS. AMYGDALITIS 



319 



Boulay supposed. The deposits are widely disseminated over the 
tonsil, distant from one another, firmly adhering, persistent, not sur- 
rounded by an inflamed surface, pale and dry, and easily distinguished 
from follicular deposits and membranes by their appearance, course, 
and microscopical structure. Loose deposits may be scraped off, 
and the sore surface (in docile children) touched with concentrated 
carbolic acid, or silver nitrate either solid or in strong solution, or 
mitigated tincture of iodine, or Lugol's solution. Potassium chlorate 
in frequent small doses internally. 

Follicular amygdalitis, the process being in the depths of the fol- 
licles, is liable to cause more general symptoms. High fever, pain, 
headache, even convulsions are very common. Epithelia, detritus, 
and a great variety of microbes form the tufts rising out of the fol- 
licles and the membranes in which a number of tufts coalesce. 

Parenchymatous inflammation of the tonsils shares the character 
and symptoms of phlegmonous pharyngitis in general, sometimes to 
an unusual degree. It results from or follows the (catarrhal or) 
follicular variety. Being caused by the latter, it is at first circum- 
scribed, the abscess originating in a single follicle. That is why it 
is mostly on one side only, but may occur once or twice a year until 
all the follicles are destroyed by suppuration. An early incision 
should be made and followed by disinfectant gargles or medicine 
(potassium chlorate). 

The abscesses of phlegmonous phargyngitis may be found any- 
where, without a trace, perhaps, of a microbic cause. Some are found 
in the submucous tissue, some hidden behind a tonsil. They require 
an early incision. Erysipelas of the pharynx has no tendency to sup- 
puration, but to considerable swelling, which may be so intense as 
to demand tracheotomy. If intubation be possible, it should be pre- 
ferred. Ice applications ; ice-pills. Baginsky recommends a five-per- 
cent, ichthyol vaseline ointment. 

The chronic form of parenchymatous amygdalitis is sometimes 
congenital (often hereditary), otherwise the result of repeated acute 
processes. Scrofula predisposes. In five per cent, of a large number 
of examinations the swelled tonsils were tubercular; in them tuber- 
culosis is either primary or secondary to pulmonary or other tubercu- 
losis (even the miliary acute form). Neighboring lymph-bodies may 
become infected from them ; less so, it appears, the follicular glands of 
the base of the tongue. Mouth-breathing, vertigo, nocturnal (morn- 
ing) cough, dyspnoea, incontinence of urine, night-terrors, ear affec- 
tions, mental hebetude, rheumatic affections, and insufficient develop- 
ment of the chest are symptoms or consequences. The chronically 



320 DISEASES OF THE DIGESTIVE ORGANS 

enlarged mass cannot be influenced by medication or astringent appli- 
cations. It is useless to tamper with caustics of any kind. Resection 
is the only quick relief, to be followed, mainly during epidemics of 
diphtheria, by disinfectant washes or medicines. If the anterior arch 
of the soft palate is adhering to the tonsils, it must be loosened first 
to avoid hemorrhage. For the same reason the tonsil should not be 
drawn out too much, nor the instrument unduly pressed in. If this 
occur (the tonsillar artery has large branches in the capsule), the 
readiest means to suppress it is digital compression inside. If the 
operation be objected to, the galvano-cautery (after anaesthesia by 
cocaine) may take its place. 

Follicles which remain open and permit a probe to enter a centi- 
metre and more are the causes of constant annoyances, new deposits, 
microbic invasions, etc. They ought to be burned out with the electro- 
cautery or ripped open with a rectangular hook suggested by Moritz 
Schmidt and improved by Gleitsmann, who sharpens one of the 
edges. 

Hemorrhages from the pharynx are not very infrequent, mild or 
grave. The treatment should be indicated by the causes; nasal and 
naso-pharyngeal and pulmonary bleeding may be mistaken for pha- 
ryngeal. Pharyngeal catarrh, varicosities of the posterior aspect of 
the uvula, and varices of the base of the tongue and the lingual tonsil 
are occasionally met with. A foreign body or an attack of whooping- 
cough may burst blood-vessels; haemophilia, scurvy, and leucocy- 
thaemia may predispose to bleeding. In infectious fevers, mainly in 
diphtheria, mild (or grave) nasal and pharyngeal hemorrhages may 
occur. Greenhow on Diphtheria, i860, p. 209, relates : " Mr. Wil- 
liams had a fatal case in which the patient died apparently from the 
profuse discharge of bloody sanies resembling claret from the throat, 
amounting to two pints per day." Similar cases we saw often during 
grave epidemics thirty and more years ago. Operation on a tonsil 
may cause it, primarily or secondarily. Primary or secondary hemor- 
rhages after incision or rupture of blood-vessels are not rare. Ulcera- 
tions of syphilis are not often found in children. Septic ulcerations are 
frequent, and usually give rise to small bleedings. When large blood- 
vessels are eroded, hemorrhage may prove fatal. I have known the 
internal carotid to bleed four times during several days in a child of 
four years until she died. The artery should have been ligated. 

2. Retro- and Later o-Pharyngeal Abscess. 
The lymph-nodes of the posterior wall of the pharynx drain the 
tonsils; the deep facial glands the orbit, jaw, pharynx, and middle 



HEMORRHAGES FROM THE PHARYNX. ABSCESS 



321 



ear; the superior deep cervical glands the cranium, larynx, thyroid, 
and pharynx. The rapid growth and intense hyperemia of all the parts 
concerned during the first year of life, the frequency of stomatitis, 
pharyngitis, and rhinitis, also otitis, and the activity of the lymph- 
system at that period explain the frequency of retro-pharyngeal ab- 
scess in the second half of the first year. After the completion of the 
second year it is rare ; after that the importance of the lymph-bodies 
of that region diminishes from year to year. In the adult the lateral 
pharyngeal lymph-bodies exist, but they are small; a number of 
small accessory lymph-bodies alongside the pharynx apparently be- 
come atrophied. Cases depending on genuine caseous tuberculosis of 
lymph-nodes are very rare ; those resulting from caries of a vertebra, 
which sometimes runs a protracted course without any symptoms, 
not frequent. After all, Koplik (N. Y. Med. Jonrn., April 4, 1896) 
justly declines to accept the existence and name of idiopathic abscess ; 
he, Neumann, and others found strepto- and staphylococci in all; 
indeed, nothing should be called idiopathic the cause of which is 
primarily located in another organ, or at a distance, though in the 
same class of tissue. The worst cases are those developed out of 
scarlatinous pharyngitis or during erysipelas (rare) or measles, also 
typhoid and influenza ; they have a tendency to become gangrenous 
and to descend into the mediastinum, or to be, on the basis of uniform 
infection, complicated with pneumonia or suppurative pleurisy. That 
is so principally when the small lymph-bodies situated in the succulent 
tissue between the pharynx and the prevertebral muscle are affected. 
It is these abscesses that perforate behind the pharynx and oesophagus 
and have a tendency to descend. The diagnosis is secured by dysp- 
noeic, interrupted, snoring respiration, stiff neck (often held back and 
sideways), difficult deglutition, tinny voice, which will not be forgotten 
if once heard, frequently by the occurrence of a lateral swelling which 
can be seen outside, and by the presence of a posterior or lateral 
swelling which can more often be felt than seen. The symptoms 
are mostly urgent, sudden deaths not uncommon, and the abscess 
should be opened when felt or even indistinctly felt to fluctuate. No 
anaesthesia. Hard swellings (in rare cases syphilitic) should not be 
incised. The finger should never be permitted to burst an abscess, 
though ever so soft: for, the pharyngeal space being narrow (the 
larynx, as shown by Symington, is higher by one vertebra in a child 
than in an adult), pus, which is usually quite copious, may be forced 
into the larynx. The abscess may be opened in most cases by a 
hard silver probe or director, which is run in quickly and made to 
tear a long opening, in others with a bistoury covered to nearly its 

21 



322 DISEASES OF THE DIGESTIVE ORGANS 

point with adhesive plaster, or, better, with a covered knife which is 
withdrawn at once and the sheath of which is used to enlarge the 
opening. Immediately after the incision the head of the patient 
should be thrown forward and gentle pressure employed laterally. 
There is rarely any hemorrhage; if there be, ice may be forced into 
the mouth; or ice-water injected into it forcibly, a single moment, 
will contract by reflex the small bleeding vessels. A gauze tampon is 
rarely required. A sponge with a solution of antipyrin (from ten to 
fort}^ per cent.) will seldom be required. If the opening is large 
enough, a second incision will not often be necessary. When the 
tonsils are, and always have been, large, it has become necessary to 
begin the operation with the resection of a tonsil. In all cases in which 
the lateral swelling is large and fluctuating, or where the abscess is 
due to vertebral disease or to scarlatinous or other sepsis, it is best 
to incise laterally behind the sterno-cleido-mastoid muscle when the 
abscess is below the larynx, in front of that muscle when the abscess 
is above it, and to disinfect and drain. This method should not be 
followed except in the cases indicated, or when the mouth cannot 
be opened (contraction of the masseters), or when the presence of 
the abscess is diagnosticated, but its location such as not to be reached 
by an incision from inside. The after-treatment is like that of phleg- 
monous pharyngitis generally. 

The diagnosis from a hsematoma or from an angiomatous tumor, 
both of wmich are rare, should not be missed ; for a mistaken diag- 
nosis may cause death. Dangerous hemorrhages may take place 
from a branch of the pharyngeal artery when the anterior palate is 
injured in a resection of the tonsil, or from a branch of the external 
maxillary artery when a peritonsillar or latero-pharyngeal abscess is 
incised far away to the right or to the left. Septic abscesses may 
also lead to the spontaneous perforation of a large artery. Four 
hemorrhages took place within six days, the last of which proved 
fatal, in a case of latero-pharyngeal abscess which resulted from 
what appeared to be a mild case of a streptococcus pharyngitis. The 
autopsy revealed a large opening in the right internal carotid, which 
should have been ligated to save the child (p. 320). 

3. Adenoid Vegetations. 
They were first described by W. Meyer, of Copenhagen, in 1870, 
and their influence on articulation, hearing, intellectual develop- 
ment, and the countenance recorded. They are lymphoid swellings in 
great numbers, sometimes covering the whole pharyngeal roof, some- 
times accumulated in one large mass (Luschka's " pharyngeal ton- 



ADENOIDS 323 

sil"), or in two masses with a groove between them. They cause or 
are dependent on or connected with catarrh of the nose, the lachrymal 
sac and conjunctiva, and the pharynx ; give rise to occasional bleed- 
ing, headache, cerebral congestion, irritability, cough, parched mouth, 
thirst, with much drinking and consequent polyuria, laryngitis, otitis, 
sometimes facial erysipelas, retard intellectual development, and pro- 
duce the expression of stupidity common to all mouth-breathers. As 
the normal nose and naso-pharynx are full of microbes, adenoid 
vegetations have been studied in reference to them. Streptococci, 
staphylococci, and pneumococci have been found on them, also lepto- 
thrix. Dieulafoy found tubercle bacilli in very many, and was dis- 
posed to claim the vegetations as tubercular; Gourc, however, not 
once in two hundred and thirteen cases, in thirty of which tuberculosis 
could be found in other organs. Dieulafoy's assumption is one of the 
many instances of the dangers, not of close investigation, but of pre- 
mature conclusions based upon the mere presence of actual or alleged 
characteristic microbes. Still, the surface on and near adenoids is 
never normal, microbic invasions are facilitated, the connection be- 
tween the lymph-ducts and blood-vessels of the base of the cranium 
and the intracranial space is very direct, and many a meningitis 
would not exist if there were no adenoids. The same microbes have 
been found in both. Contraction of the nose, pointed arching of the 
palate, and dental deviations with shortened and low inferior maxilla, 
ill-shaped, particularly pigeon-breast, also scoliosis, even funnel chest, 
are as much the results of adenoid vegetations as of original rhachitis 
or other (congenital) anomalies. F. Huber (Festschrift, 1900) re- 
ports that, " in a few cases of empyema in mouth-breathers, curetting 
of the naso-pharynx, by favoring pulmonary expansion through im- 
provement in the breathing, caused the obliteration of a small cavity 
or sinus, thereby avoiding a secondary operation upon the costal 
walls. In the same way, the associated lateral curvature rapidly 
disappeared when nasal respiration was established." He also em- 
phasizes that " the teeth show a tendency to early decay, particularly 
the molars ; in some cases stomatitis and gingivitis occur, persist- 
ing until the growths are removed." Habitual cold washing and 
friction of the whole body contribute to regulate the circulation and 
relieve local hyperemia. Nasal irrigations with salt water, boracic 
acid solutions, etc., while relieving the obstruction and catarrh of the 
naso-pharynx, are capable of reducing congestion and sometimes 
render an operation superfluous. The latter, however, is preferable 
in almost every instance when the adenoids are not quite small, and 
just as important as the removal of intractable swelled lymph-bodies 



3^4 



DISEASES OF THE DIGESTIVE ORGANS 



from the neck. As the vegetations often spread over a large sur- 
face, instruments like Gottstein's, which remove the prominences from 
a large area, are best. Delstauche's modification of that instrument, 
which consists in the addition of two sharp hooks bent downward, is 
a good one and applicable to larger tumors which can be caught. 
The small ones should be rubbed off with Gottstein's scraper. The 
instrument should not be too large and not be carried sideways, in 
order not to injure the cartilaginous edge of the Eustachian tube. 
The operation should not be performed during an infectious fever, 
particularly not during an attack of diphtheria, for fear of further 
invasion through the sore surface; it is still more objectionable here 
than it is on the tonsils, which may require resection to facilitate 
respiration in an occasional bad case of diphtheria. During or im- 
mediately after the operation the head should hang down to avoid 
bleeding into the air-passages. Bleeding will stop spontaneously, or 
by a brief compression with the finger, or an application of a sponge 
dipped in ice-water. If there be more, the pressing on of a sponge 
dipped in a twenty- or forty-per-cent. solution of antipyrin in water 
is advisable. The operation requires anaesthesia in very bad cases 
only, but should be followed by a day's rest. 

The connection of enuresis with adenoids will be discussed in 
Chapter IX. 

4. Congenital Fistula. 
It is caused by the incompleteness of the closure of the second 
branchial arch. It begins near the sterno-cleido muscle and termi- 
nates in the pharynx. Here it is either open (complete fistula) or 
not (incomplete). If open inside and closed in the middle, it forms 
a diverticulum. Cystic hygromata, unless they be lymphangiomata 
or deep-seated atheromatous cysts, result from closure outside and 
inside while the centre remains open. Multilocular cysts may be the 
result of multiple and partial closure, perhaps by the rapidly prolifer- 
ating epithelia separated from one another by copious lymph-tissue. 
The thyroglossal duct begins to undergo atrophy at the fifth week 
and is obliterated by the eighth, its upper extremity being perma- 
nently indicated by the foramen caecum on the dorsum of the tongue. 
The fistula of the duct, when it does not close, is always in the median 
line, between the hyoid bone and the sternum, and lined with ciliated 
columnar epithelium (in the lingual portion squamous). It moves 
with the hyoid bone. Injections of iodine have been made to close 
the fistula, and good results have been observed. Total extirpation 
is by far preferable. 



(ESOPHAGUS. STRICTURE. FOREIGN BODIES. ABSCESS 325 

D. The (Esophagus. 

Diseases of the mouth and pharynx descend into the oesophagus : 
catarrh, thrush, leptothrix, diphtheria. Injury by carbolic acid re- 
quires oil, also sodium sulphate in solution; by acids: chalk, so- 
dium bicarbonate, soap; by lye: fruit-juice, vinegar; by hot water: 
ice or ice-water and cold applications. The symptomatic treatment 
requires opiates. 

Stricture may be congenital (Demme). Such a case, complicated 
with communication between the oesophagus and the trachea, was 
operated upon by Helferich with fatal result. Cases of complete 
atresia, with that of the anus, of the mitral and other orifices, are on 
record. Stricture follows injuries (mechanical or chemical) after 
months or sometimes years. Above the stricture a diverticulum is 
apt to form, with the usual symptoms. Mechanical dilatation should 
be very gentle and gradual to avoid perforation; no metal instru- 
ments should be used. Gastrostomy, with or without dilatation or 
divulsion from below upward, is performed to facilitate both nutri- 
tion and dilatation from below. Hjort reports that he opened a stric- 
ture in a boy of fourteen years by electrolysis in two sessions, the 
negative pole of from ten to fifteen elements being introduced. 

Foreign bodies should be extracted, if possible, according to the 
methods taught for adults. If that be impossible because of size or 
shape, they should be forced down into the stomach. If that fails, 
cesophagotomy is indicated. Of the one hundred and twenty cases 
of cesophagotomy collected by Fischer, four were under two years, 
eleven from two to ten, four from ten to fifteen years, altogether 
with a mortality of thirty-three per cent., due more to delay, and 
consequent sepsis, than to the operation. Gerster saved a boy of 
two years, in spite of deep ulceration caused by the foreign body, 
and a girl of nine years; Alexandrofr", a boy of two years and nine 
months.* 

Pericesophageal abscess may result from descending retro- or 
latero-pharyngeal abscess. Diseases of the vertebrae (the oesophagus 
being in close contact with the cervical portion of the spine), of 
glands, pleura, and pericardium, also foreign bodies will cause it. 
Glands may be found tumefied, the larynx dislodged, and a soft swell- 
ing may be felt in the fauces. If it be within reach, an early incision 
should be made. 



F. Karewski, Die Chirurg. Krankh. d. Kind., 1894, p. 367. 



326 DISEASES OF THE DIGESTIVE ORGANS 

E. The Stomach. 
i. General Nosology. Dyspepsia. 

The indications for the therapeutics of the stomach, both dietetic 
and medicinal, are by no means simple and clear in every individual 
case; for it is difficult to make an exact diagnosis of the anatomi- 
cal condition of the surface and the tissue of the organ because of 
the frequent combination of various conditions. Indeed, the boun- 
dary line between a simple functional dyspepsia and a gastric catarrh 
is perhaps never made out clearly. The epithelium of the mucous 
membrane does not belong to it exclusively, but spreads in the 
contiguity of the tissue into the muciparous and the peptic glands. 
Thus the inflammatory condition of the surface becomes at once a 
" parenchymatous" affection, though it be possible that an uncom- 
plicated catarrh and an uncomplicated inflammation should exist. 
This, however, will last but a short time, and unless a gastric catarrh, 
or a dyspepsia, or an intestinal irritation — for the intestine shares 
the peculiar anatomical condition of the epithelium of the stomach 
— be relieved at once, the merely functional or superficial disorder 
becomes organic and deep-seated. These changes may refer either 
to the tissue or to the secretion. Inflammatory thickening, erosions, 
ulcerations, or (Moncorvo) dilatation of the stomach will be ob- 
served in a great many instances. The secretions become abnor- 
mal. The normal hydrochloric acid of the gastric juice is almost 
invariably diminished ; now and then a case will be found, but in 
older children only, in which it is increased in quantity; still, as a 
rule, it is wanting or but scantily supplied. Lactic acid, however, 
is produced in much larger quantities than the first stage of normal 
digestion requires, and with it acetic, butyric, and the rest of the fat 
acids. With this variety of changes the indications for treatment go 
hand-in-hand ; others are suggested by the multitude of etiological 
factors. The direct paralyzing influence of heat, the immediate effect 
of irritant and bulky ingesta, and the poisonous action of bacteria 
introduced in food and rapidly multiplying render the intelligent and 
effective treatment of many of the cases which occur in the practice 
of every medical man a matter of great difficulty and responsibility. 
Nothing is more common, but less appropriate, than routine treatment 
directed against a variety of cases. 

The importance of diet in all questions connected with the pathol- 
ogy of the digestive organs justifies the repetition, in this place, of 
a few main points the elaboration of which may be found in the first 
chapter of this book. 



STOMACH. PHYSIOLOGY. DIET 327 

The principal cause of the diseased conditions of the digestive 
organs of the young is to be sought for in improper food. Not even 
mother's milk will always agree with the baby; cow's milk cannot 
possibly take its place as a legitimate and satisfactory substitute. 
Much less reliance can be placed on manufactured or home-made 
mixtures of unequal composition and doubtful quality. Children of 
more advanced years resemble adults in this, that they are endowed 
with more resistance to damaging influences; but the infant and 
young child are in constant danger of losing their physiological equi- 
librium by slight changes in feeding or by the deterioration of foods. 
The readiness with which milk, which is indispensable as a food, will 
decompose, acidulate, and become indigestible renders the greatest 
attention a necessity in the interest of prevention. The difficulties are 
very great; that is why it happens that an otherwise objectionable 
food (permissible so long as nothing absolutely good can be had), — 
that is, condensed milk, — when properly preserved and delivered daily 
at the dwellings of the poor, is preferable to food of a suspicious 
character. Attention must first be directed to the differences between 
cow's and woman's milk. The former contains more casein, usually 
a little less fat, sugar, and sodium chloride. Besides, the caseins 
of cow's and woman's milk differ both chemically and physiologically. 
That has always been so, and will be so, though a recent journal 
article declares the fact — or its assertion — a " bugbear." The former 
is less digestible, and its amount in the food given an infant must 
not be larger than one per cent., rather smaller. On the other hand, 
a large percentage (from nine to twelve) of fat is contained in every 
normal defecation of an infant fed on breast-milk; thus care should 
be taken not to exceed the quantity of fat contained in infant food 
when artificial feeding is resorted to. That is important because the 
fat of cow's milk differs both chemically and microscopically from 
that of woman's milk. Indeed, to what extent fat administered in 
excess, and indiscriminately, is apt to produce diarrhoea is best illus- 
trated by the " fat diarrhoea" which has been a frequent topic for 
discussion in medical journals. Water, salt, and sugar must be 
furnished the infant in sufficient quantities. (See Chapter I.) 

Water is often wanting in infants' and children's food, and its 
absence is the cause of dyspepsia and of anatomical changes in the 
digestive organs. Its role in the organism is very manifold. Besides 
its influence on general metamorphosis, it is required to assist in 
pepsin digestion. In artificial digestion, ^albumin is liable to remain 
unchanged until large quantities of acidulated water have been sup- 
plied. Peptones, even in the stomach, require water to facilitate their 



328 DISEASES OF THE DIGESTIVE ORGANS 

solution and absorption. The immediate relief felt from a draught of 
water taken during the precordial heaviness and discomfort experi- 
enced after a hearty meal is a matter of daily experience. Infants 
and children — mainly the former — receive too little water. When- 
ever they are thirsty, both in winter and in summer, they are given 
milk, — that is, food; and many a case of dyspepsia, with its results, 
could be obviated by adding plenty of water to the food. Excess of 
water, if under ordinary circumstances there is such a thing, is at- 
tended by less inconvenience or danger, for it is readily absorbed and 
eliminated in the conditions it meets in the stomach, which holds salt 
and sugar. 

Sodium chloride ought to be added to most foods of infants and 
children. For instance^ vegetable diet contains more potassium and 
less sodium than all the varieties of milk, and milk of herbivores 
more potassium than that of carnivores. Thus, cat's milk contains 
sodium i to potassium 0.76, woman's milk 1 to 1.13 or even 4.4, and 
sheep's and cow's milk 1 to 5.6. The amount of salt contained in 
woman's milk depends greatly on the presence of salt in her food. 
Therefore, many a defective milk can be remedied by the mother or 
wet-nurse by adding salt to her food. Particularly is this necessary 
in dyspepsia and gastric catarrh in the baby, one of the main symp- 
toms of which is the presence of large and hard curds in the masses 
brought up by vomiting or evacuated by the rectum. The addition 
of sodium chloride to milk impedes or delays the solid curdling by 
rennet, — a physiological fact which explains the usefulness of salt 
in every kind of infant food; for in vegetables, and mainly in fari- 
nacea, the disproportion of potassium and sodium is still more evident 
than in milks. 

Souring of milk is prevented by boiling, mainly through the ex- 
pulsion of a large quantity (three per cent.) of gases (carbonic acid, 
nitrogen, and oxygen) contained in the milk when it leaves the udder, 
and by the destruction of parasitic growths. That is why I have 
always advised to boil the milk destined for the use of a baby as soon 
as obtained, fill it hot into bottles, containing from three to six ounces, 
up to the corks, close them tightly, and preserve them inverted in 
a cool place. Whenever a meal is to be prepared, the milk thus pre- 
served should be heated again up to or near the boiling point, — pref- 
erably in a water-bath. That process should be repeated perhaps 
several times a day ; while one bottle is being heated, the others may 
undergo the same procedure, for every boiling interrupts the begin- 
ning of lactic acid or other decomposition. The sterilization (or 
pasteurization) of milk in Soxhlet's apparatus is a still better pro- 



STOMACH. PHYSIOLOGY. DIET 329 

ceciure. Milk properly sterilized will keep one or more days, but 
for general use among those who cannot obtain (or pay for) the pat- 
ented apparatus my method will suffice under ordinary circumstances 
and for people with the most ordinary intellect. 

A certain amount of starch is digested at the very earliest age, 
for saliva is secreted at that time. Its effect persists in the stomach 
so long as the hydrochloric acid in the gastric secretion does not 
exceed 0.06 per cent. ; within the first half-hour of the digestive 
process there is none at all, but organic (mainly lactic) acid only. 
Thus, though starch pass the oral cavity rather quickly, it will still 
undergo its change into dextrin in the stomach. In many abnormal 
conditions this digestive change lasts a still longer time; for in- 
stance, in fevers, in severe gastric catarrh, and in dilatation of the 
stomach. These are the conditions in which farinaceous foods are 
best tolerated, for the reasons that the diastatic effect of the saliva 
is not disturbed, and that albuminoids cannot be digested because 
of the absence of hydrochloric acid (and pepsin). In all normal and 
many morbid conditions amylaceous foods, when present in certain 
quantities, have additional functions. Besides being nutritious in its 
own way, starch serves to dilute cow's milk, to reduce the percentage 
of casein in the mixture, to prevent the latter from coagulating in 
large masses, and thus to render it more digestible. The reasons 
why I prefer in most instances either barley or oatmeal, and in others 
gum-arabic or gelatin, and do not recommend (p. 327) condensed 
milk, etc., have been given above.* (See Chapter I.) 



* F. A. Hoffmann, in Lectures on General Therapeutics, Leipsic, 2d ed., 
1888, p. 223, says in connection with the rules on infant feeding annually 
published by the New York Health Department, which he copies, " Unless 
woman's milk can be had there is a great danger in the probability that the 
sensitive intestinal tract be supplied with injurious material; for such is 
the very best cow's milk in the cases of very young infants, because the mix- 
ture of its constituents differs greatly from that in woman's milk, and its 
casein is less digestible. Both physicians and manufacturers have tried to 
compound substitutes for woman's milk, but those only the composition of 
which is known should be noticed by scientific men and recommended. An- 
other requisite is this, that such a food must be within the means and under- 
standing of everybody, and that a certain supervision be possible. Jacobi's 
treatise in Gerhardt's Manual of Pediatrics will be found satisfactory by all 
those who desire to inform themselves on all that is known. From my own 
experience, I confirm his recommendations to dilute milk with barley- or 
oatmeal-water. At present the hope has been expressed that all this may 
be replaced by the sterilization of milk, but in practice there will be many 
impediments and obstacles. Sterilization can have but one result, — viz., to 



330 



DISEASES OF THE DIGESTIVE ORGANS 



From what I have said I draw the conclusion that so long as a 
baby is not nursed by a healthy woman, the opportunities for acquiring 
some kind of gastric disorder are very numerous indeed. Dyspepsia 
is therefore quite frequent. Its treatment consists in more or less 
abstinence and in the regulation of the diet. As a rule, food should 
be more diluted than usually. As the gastric contents of infants who 
have been brought up on artificial foods are liable to be very acid, 
alkalies in small doses, and frequently administered, have a good 
effect. Bismuth subcarbonate may be added. When there is vomit- 
ing, it must be determined whether it is gastric, and from what 
cause. Those who are in practice know too well how often they 
have seen meningitis mistaken for a gastric disorder, and how 
common is the occurrence of that symptom in the incipient stages 
of all kinds of inflammatory fevers. When all these and the local 
irritation of the stomach (brought on by foreign bodies, such as 
bulky foods, or by the presence of ascarides) and nephritis can be 
excluded, only then the vomiting should be considered gastric exclu- 
sively. Now and then abstinence only, or the drinking of warm 
water or warm mustard water to facilitate vomiting; or alkalies 
(sodium bicarbonate, magnesia, calcium carbonate), or alkalies with 
bismuth ; or resorcin to disinfect the contents ; or dilute hydro- 
chloric acid for disinfection and to correct the nature of the gastric 
acid; or the washing out of the stomach with warm water or salt 
water (6 or 10 to iooo), or with a sodium bicarbonate (i to ioo or 
200) or a resorcin (1 to 50 or 100) solution; and, finally, after the 
stomach has been freed of its injurious contents, small doses of opium, 
from one-half to one and a half milligrammes (one-one-hundred-and- 
twentieth to one-fortieth grain), every hour or every two hours, or 
its equivalent in morphine or codeine, will prove satisfactory. Pro- 
tracted and obstinate vomiting I have seen getting well with minute 
doses of arsenous acid, from a thousandth to a four-hundredth part 
of a grain every hour or every two or three hours, according to 
the age of the patient or the individual indications of the case. 
Small doses of ice-water or, better still, ice-pills repeated every 
five or ten minutes will answer in many instances. Effervescent 
drinks, iced, such as teaspoon doses of Apollinaris, Seltzer, or Vichy, 



remove the danger arising from the decomposition of milk. But, after all, 
it is cow's milk and not woman's." 

It is a source of gratification to the writer to learn that he has not been 
vvrong in his practice and teaching. Biedert and Heubner also advocate the 
use of cereals. 



ACUTE GASTRIC CATARRH. GASTRITIS 331 

or champagne, may do fairly well in certain cases, but less fre- 
quently and less happily than in most adults under the same 
circumstances. 

2. Acute Gastric Catarrh. 

When it is produced by injurious ingesta, these ought to be re- 
moved. If vomiting have not occurred spontaneously, or not suffi- 
ciently, it should be produced by the above-mentioned drinks, tickling 
the fauces, friction of the precordial region, ipecac, — the syrup is 
very often an unreliable preparation, — or other emetics. In cases 
of great urgency only the subcutaneous use of apomorphine may be 
resorted to. The mildest (and quite safe) way of emptying the 
stomach is by irrigation. Purgatives must not be given in the be- 
ginning; large enemata will act more favorably. They may consist 
of warm water, warm water with antispasmodics, such as assafcetida, 
or with stimulants, such as turpentine. After a day or two a purga- 
tive dose of calomel will answer. Fever, unless it be high, requires 
no special treatment; in urgent cases only antipyrin may be given, 
either by mouth or rectum or subcutaneously. Tendency to con- 
vulsions requires cold to the head or cold applications to the heart, 
which will reduce both the irritation of that organ and the tempera- 
ture of the blood. A warm bath will often do good, but the cus- 
tomary bathing and jostling and tossing of a baby in convulsions 
do more harm than good. Thirst should be relieved by water, car- 
bonic acid water, or water acidulated with dilute hydrochloric acid 
(1 to 300 or 500). 

No solid food. Milk should be given in small quantities only, 
diluted with water, lime-water, barley-water, or on Rudisch's plan 
(dilute hydrochloric acid 1, water 250, milk 500). Vomiting is 
to be treated on the plan detailed above, predominance of acids 
by alkalies, constipation by calcined magnesia in small and frequent 
doses rather than by drastics. The aqueous tincture of rhubarb, 
in doses of from ten to thirty minims every few hours, will prove 
very satisfactory in many cases. 

3. Gastritis. 
Severe forms of gastritis — the corrosive, diphtheritic , and suppu- 
rative varieties — require cold applications to the epigastrium, and 
opium in the most available form ; in the beginning, morphine sub- 
cutaneously. The corrosive form demands neutralization of the poi- 
son first: salt water for silver nitrate, diluted acids (vinegar) for 



332 DISEASES OF THE DIGESTIVE ORGANS 

lye, alkali (chalk, magnesia, baking-soda, soap) for acids, sodium 
sulphate or oil for carbolic acid, egg, water, and milk for corrosive sub- 
limate, copper sulphate largely diluted for phosphorus, lime-water for 
oxalic acid, freshly precipitated ferric hydrate for arsenic, etc. All 
of these require total abstinence, which may be continued for more 
or less time. How long it ought to be endured depends on the condi- 
tion of the patient and the good judgment of the medical adviser. 
Adults will bear it many days and infants and children from twelve 
to thirty hours. If such absolute rest be demanded longer than this 
period, nutritive injections into the rectum should take the place of 
feeding by the stomach. The rectum and the rest of the large intestine 
digest no albumin and emulsionize no fat, but they transform, starch 
into dextrin and cane-sugar into grape-sugar ; moreover, they absorb 
peptones of every kind, egg, emulsionized fat, and starch (p. 47). 
In all cases of rapid elimination of water by vomiting, or of utter 
exhaustion in gastro-intestinal catarrh with imminent thromboses in 
the small cerebral veins (" hydrencephaloid"), the hourly or two- 
hourly injection of salt water (the usual strength) into the rectum 
in doses of an ounce or much more will fill the blood-vessels and 
restore circulation. 

4. Chronic Gastric Catarrh. 
It is sometimes dependent on or interrupted by acute catarrh ; 
the attacks of the latter must therefore be promptly relieved. The 
several causes of chronic gastric catarrh have their own indications. 
Both in adults and children venous congestion resulting from pul- 
monary or cardiac diseases will give rise to it; thus in many cases 
digitalis in small doses, continued a long time, will be the rem- 
edy or one of the measures of relief. Sedentary life must be avoided, 
school hours and private lessons kept within reasonable limits, and 
regulated by the meals rather than that these should be controlled 
by the former. Masturbation must be watched: I have seen it to 
be the cause of gastric disturbances exactly as in adolescence. Diet 
and food want attention. Most children eat too much, and many 
too irregularly. Solid food is to be given but scantily ; no sweets, 
no fat, which will cause hyperacidity, that must be prevented or 
treated with alkalies like a genuine hyperchlorhydria (excessive for- 
mation of hydrochloric acid). Eating must be slow and mastication 
careful. Toasted bread or stale wheat bread, milk diluted with cereals 
or according to the muriatic acid plan (Rudisch), or peptonized 
(but not to bitterness), — everything of moderate temperature or hot, 
— will answer ; in many cases small quantities of cold, fresh butter- 



STOMACH. CHRONIC CATARRH. DILATATION 333 

milk. Slowness of digestion, with heavy sensation about the epi- 
gastrium, demands additional sodium chloride, sodium bicarbonate, 
effervescent alkaline drinks ; fermentation indicates resorcin, or creo- 
sote in doses of from one-quarter to one-half of a drop. A few 
grains of salicylic acid diluted in large quantities of water (1 to 
500 or 1000) may also be tried. Rhubarb and magnesia, rhubarb 
and sodium bicarbonate, tinctura rhei aquosa, render excellent ser- 
vice. When there is a great deal of mucus, dilute hydrochloric acid 
with small doses of pepsin are indicated. When the tongue is thickly 
coated, with eructations, ammonium chloride (from half a gramme to 
one gramme daily) with tinctura rhei aquosa; the tendency to vomit 
and to pain demands bismuth, in older children Carlsbad, Congress, 
or stronger (bitter) waters. These measures may be continued for a 
long period ; bismuth may be given indefinitely in small doses ; zinc 
sulphate can be administered (doses from one-twenty-fifth to one- 
sixteenth of a grain = two to four milligrammes every few hours) 
a long time, silver nitrate (doses of one-thirtieth or one-fifteenth 
of a grain = two or four milligrammes several times daily) for not 
more than a week in succession. 

Occasionally irrigation of the stomach is resorted to with advan- 
tage, and may be repeated. 

5. Dilatation of the Stomach. Stenosis of the Pylorus. 
It is not very frequent in early infancy, but results from extension 
by gas (overfeeding with amylacea) under the influence of feeble 
muscular development (congenital, rhachitis, anaemia, parasyphilis). 
The treatment may include an occasional irrigation of the stomach, 
and must consist of appropriate diet. The same indications hold good 
in the older child, besides those which are furnished by the very 
extensive etiology. Dilatation of the stomach in the child is by no 
means rare. When met with in the adult, it dates often from 
(infancy or) childhood. Its causes are overfeeding in general and 
with amylaceous material in particular; rhachitis with consecutive 
muscular debility ; voracity, imperfect digestion, and gas inflation ; 
catarrhal inflammation with diminished absorption ; general muscular 
incompetency, as in anaemia and convalescence ; congenital imperfec- 
tion or partial absence of muscular tissue in the wall of the stomach ; 
paralysis of the stomach, of central origin ; hypertrophy and total or 
partial obstruction of the pylorus ; cicatrized ulceration of the stom- 
ach near the pylorus, or of the duodenum ; or peritoneal adhesions 
of the stomach resulting in a triangular or quadrangular shape of 
the dilated organ. 



334 DISEASES OF THE DIGESTIVE ORGANS 

Dilatation of the stomach in the newly-born or the very young 
infant is the result of stenosis of the pylorus, the normal diameter 
of which is at birth six and one-third millimetres, at the end of the 
first month seven millimetres, and one-third of a millimetre more 
with every month thereafter. The narrowing of the pylorus is either 
organic or functional. There is a congenital hypertrophy of the cir- 
cular (in a case of Finkelstein the longitudinal) muscular layers of 
the pylorus (Hirschsprung, 1887) ; the dilatation of the stomach 
may be followed by that of the oesophagus. Death follows within a 
few weeks or months, and autopsies reveal the exact condition. 
Such cases require surgical interference. Such a congenital hyper- 
trophy may exist with all the symptoms of dilatation (even visible 
outlines of the descended lower curvature, and contractions of the 
stomach, vomiting, constipation mostly, etc.) without any spasm; but, 
on the contrary, it may safely be assumed that when there is originally 
a spasm, hypertrophy may be caused by it. 

Such a congenital or infant spasm of the pylorus certainly exists. 
John Thomson, Pfaundler, and others believe in a spastic condition 
of the pylorus as the cause of its stenosis, that spasm being compara- 
ble with the tenesmus in anal fissure or ulceration, in vaginismus, or 
in blepharospasm. That is why careful and scanty nutrition (rectal 
alimentation) and sedatives (belladonna, opiates) and warm fomen- 
tations are expected to do good. When there is an excess of acid in 
the contents of the stomach, an occasional irrigation with sterile water 
or a slightly alkaline solution, and the administration of lime-water, 
calcium carbonate, or sodium bicarbonate is indicated. Nicoll and 
Meinhard Schmidt report a case in which the stomach was opened and 
the pylorus dilated, with good results. In some cases of genuine pri- 
mary hypertrophy gastro-enterostomy has been performed successfully. 

In dilatation of the stomach of more advanced age antifermenta- 
tives should be given, such as bismuth, silver nitrate, calomel, or 
resorcin; all of these in small but long-continued doses. The quan- 
tity of food taken at one time should be small; the meals should be 
numerous. Nothing should be given that is apt to ferment, like 
fat and great quantities of starch ; a certain amount is digested ; 
when too slowly, taka-diastase may be tried. Large amounts of fluid 
should not be given. Milk in small quantities may be given often. 
Diarrhoea may require gallic acid and other astringents ; it depends 
upon the condition of the stomach ; indeed, most cases of consecutive 
diarrhoea will be best treated by attending to the stomach. Raw beef 
is among those articles of food which are most easily digested, and 
beef peptones in small quantities are very useful. Raw milk is not 



STENOSIS OF PYLORUS. NERVOUS DYSPEPSIA 335 

so easily digested as boiled. Peptonized milk and Rudisch's prepa- 
ration should be tried. A bandage should be worn about the abdomen. 
The faradic and galvanic currents can be used with advantage. Ac- 
cording to Ewald, electricity and massage accelerate the passage of 
chyme into the intestine. It seems to me, however, that it is question- 
able whether digestion was improved by them, for it may be that both 
of these applications resulted in opening of the pylorus before the 
gastric digestion was finished. Einhorn's method of using the elec- 
tric current in the interior of the stomach is hardly applicable to 
infants and children. Preparations of nux vomica — the tincture — 
or strychnine in three daily doses of from one-one-hundred-and- 
twentieth to one-sixtieth of a grain each (one-half to one milli- 
gramme) will improve the muscular tone of the stomach. When the 
dilatation of the stomach depends on adhesions, operative procedures 
may be considered. 

6. Nervous Dyspepsia. 

Its therapeutics must be simple ; its effect is not very encouraging- 
Food should be digestible and sufficiently copious. Purgatives should 
never be given ; enemata must take their place, if required. Bitter 
tonics, country and sea air, cold bathing or sponge-baths, electricity, 
one large electrode being applied to the stomach and another to the 
spinal column, are indicated. In these cases, which are not quite 
rare among older children, particularly those with early and obstinate 
chorea and other symptoms of ansemia and " neurasthenia," mild 
preparations of iron and of arsenic are among the very best remedies, 
and should be continued a long time. Training, arsenic, and hydro- 
therapy will relieve many an obstinate case by improving general 
health and will-power. 

Rumination (merycism) I have exclusively seen in neurotic indi- 
viduals, mostly adolescents, all of whom were devoted masturbators. 
The only case I have seen in a boy of eight years was also that of a 
diligent onanist. The food, mostly amylaceous, returns after every 
meal in instalments, until part of a meal or a whole meal comes up 
again; finally it stops, the last returns being acidulated. There is 
rather a pleasant sensation connected with it. Hyperacidity or 
anacidity has nothing to do with it. It has been observed in families, 
and small children of two years and over were affected. That would 
point to a neurotic tendency, or to a (atavistic?) peculiar condition 
of the stomach, which has been found to be divided into well-marked 
compartments. My own therapeutical measures were directed against 
the detrimental habit and to invigoration. 



336 DISEASES OF THE DIGESTIVE ORGANS 

7. Gastric and Duodenal Ulceration. 

With or without hemorrhage, gastric ulcer is not very uncommon 
in the newly-born, the infant, and particularly in children of from 
seven to thirteen years. Fatal hemorrhages, besides " melaena neona- 
torum," have been observed, by me and others, even in infants. Nor 
is duodenal ulcer very rare. Of Collin's two hundred and seventy- 
nine cases, forty-two belong to the first decade of life, seventeen of 
them to the first year. It is met within a few days after birth, and 
probably depends not so much on intra-uterine defect as on throm- 
bosis of the umbilical vein and embolism of the vessels of the small 
intestine (Landau). Kinnicutt (Festschrift) emphasizes the causal 
effect of burns and of septicaemia, and the common occurrence of 
complication with nephritis, the frequency of which in infancy and 
childhood, from all sorts of causes and with many complications, 
should always be remembered. Hemorrhage requires absolute rest in 
bed, ice-bag to the epigastrium, morphine under the skin in appro- 
priate doses, ice-pills, ligature of the lower extremities to compress 
veins for half an hour only ; if tolerated, lead acetate may be given. 
No matter whether the cause be an embolic process, or a chronic 
catarrh of long standing, or a local injury (caustic or foreign bodies, 
stones, a safety-pin in a baby of eight months), the circulation in 
the parts is interrupted and the normal alkalinity of the tissues de- 
stroyed. Thus these are constantly exposed to the injurious effects 
of the gastric acids, similarly to what occurs in the dead body when 
the action of the acids on the non-secreting gastric surface results 
in softening and perforation of the wall (" gastromalacia"). 

The first indication is to keep the stomach and duodenum as 
alkaline as possible, at all events between meals. Now, the intro- 
duction of any food will give rise to the secretion of gastric juice, 
which is first lactic, afterwards hydrochloric acid; a certain amount 
of both is required for normal digestion. Whatever there is, how- 
ever^ in the stomach of acid or acids which are not required for the 
physiological process, particularly acetic, butyric, caprylic, or only an 
excess of lactic acid, must be neutralized. An occasional dose of an 
antacid is not sufficient for that purpose, but it must be given regu- 
larly and for a long time. I generally give the doses at intervals of 
two hours. I also give a dose a few minutes before each meal to 
neutralize every abnormal acid, no matter whether the patient is an 
adult or a child. 

Which antacid is to be selected, — the potassium, sodium, calcium, 
or magnesium salts ? Of the latter, I prefer calcined magnesia to the 



GASTRIC AND DUODENAL ULCERATION 



337 



carbonate, to obviate the expulsion of free carbonic acid into the stom- 
ach. I use it frequently, but rarely (for a child) in larger doses than 
from eight to ten or twelve grains (0.75) daily. A small part of 
this, say one grain (0.06), is taken every hour or two, before meals, 
mostly in water, which should not be too cold; hot water is even 
better. More than that quantity is seldom tolerated because of diar- 
rhoea caused by it ; still, its purgative effect is very welcome in patie^ 
suffering from constipation ; these may take larger doses. W^ 
above quantity does not suffice to neutralize the acids, or : 
that more magnesium may cause diarrhoea, it may be l 
the carbonate or the phosphate of lime. Sodium bicarbon 
take the place of the calcium and magnesium so readily, .^n 

as it also appears to promote the secretion of gastric juice. 1 here- 
fore, in most cases, I use magnesium or calcium with or without 
bismuth subcarbonate, or such adjuvants, if any, as may appear to 
be indicated for other reasons. The addition of small doses of an 
opiate is indicated (only) when the intense motory action of the 
stomach is to be quieted. * 

This medicinal treatment must be continued for weeks or months ; 
without it I do not see gastric or duodenal ulcers getting well. 

The Carlsbad waters, and salines in general, owe their effect 
partly to their neutralizing and partly to their purgative influence. 

The effect of lime-water is illusory, if given for the purpose of 
neutralizing the acid, unless in sufficient quantities ; it contains only 
a single grain to nearly two fluidounces (50.0) of water. But when 
added to cow's milk in sufficient quantities (1 to 2 or 3) it certainly 
makes it more digestible. 

The very function of the diseased organ involves danger. Both 
the stomach and the duodenum should be kept as idle as possible, 
and their labor should be made easy. Indigestible food must not be 
given and solid food must not be allowed. Most older children toler- 
ate boiled milk, strained oatmeal, barley gruel, stale wheat bread, 
and a few also raw beef. Some take nothing but boiled milk, or 
buttermilk, or koumiss. Many, particularly adolescents or adults, will 
tell you that they do not digest milk. That may be true ; but then they 
gulped it down, and it formed in the stomach a large cheese-cake 
that was not afterwards dissolved and digested. They should boil 
their milk in the morning and heat it several times during the day 
almost to the boiling point, or should pasteurize it for the day. They 
should add a small quantity of table salt, provided their stomach is 
not too acid, for the sodium chloride may increase the gastric hydro- 
chloric acid ; also, in case the stomach is very acid, some sodium, 

22 



338 DISEASES OF THE DIGESTIVE ORGANS 

or calcium, or magnesium bicarbonate, and no salt. They should not 
drink their milk, but pour it into a plate and sip it with a spoon. 
Thus prepared, they will digest it, particularly when it is not quite 
cold. In fact, many require their meals warm or hot. 

For the purpose of easier digestion, milk may be peptonized, or 
it may be rendered more digestible by the process recommended by 
J. Rudisch, or mixed with farinaceous decoctions as recommended 
above. 

With an alkaline condition of the surface and an innocuous diet, 
the ulcers have an opportunity to heal. This may be aided by the 
administration of silver nitrate. A child may take from one-thirtieth 
to one-twentieth of a grain (two to three milligrammes) in a table- 
spoonful of distilled water four or five times a day; if possible, on 
a fairly empty stomach. Or a smaller quantity may be given in 
a pill with or without a small dose of opium, say one-sixtieth to 
one-fifteenth of a grain (one to four milligrammes) in each pill. 
Sometimes I give but a single dose at bedtime in addition to the 
alkaline treatment. Silver nitrate must not be given beyond a reason- 
able time, to avoid argyria. 

Tincture of iodine, in doses of from one to three drops for the 
adult, of one-half to one drop to a child, well diluted with water, has 
often been recommended. Its action is probably antifermentative 
here as in chronic gastric catarrh. 

When there are much pain and a great deal of acid or other secre- 
tion, opiates are indicated. Chloral is tolerated badly. Papain, which 
acts quite well in chronic gastric catarrh, is not indicated in ulcer, 
hyperacidity, or in the presence of a neoplasm. 

Operations recommended for gastric ulceration are, first, excision 
of the ulcer; second, gastroenterostomy ; third, pyloroplasty; fourth, 
resection of the pylorus ; also cauterization of the ulcer and liga- 
tion of the bleeding vessels near the ulceration. These methods are 
difficult, take time, and the operation must be performed on an ex- 
sanguinated patient. Witzel, therefore, ligated the efferent blood- 
vessels without opening the stomach (the right and left superior 
coronary arteries), with good result (Deutsche Zeitsch. f. Chir., vol. 
lxii.). 

Bad cases require rest in bed, particularly those of anaemic girls 
(and women). 

The stomach has a better opportunity to get well when at rest 
than when at work. Thus it sometimes becomes necessary to abstain 
altogether from feeding by the mouth. Rectal alimentation is then 
resorted to to great advantage. In conditions of such genuine starva- 



NEOPLASMS OF STOMACH. CONSTIPATION 



339 



tion the lymphatics are very greedy and absorption from the rectum 
is very active. 

Ulcer of the stomach, both in the young and old, being frequently 
associated with intense anaemia, the result, in these as in many other 
cases, is mistaken for the cause. Then iron, the great presumed 
panacea for anaemia, is often introduced into a stomach which can- 
not digest it, and, in its attempts to do so, pain and ulceration, with 
their dangers, are increased. One of the dangers is a cicatricial 
obstruction of the pylorus with dilatation of the stomach. 

Carcinoma and sarcoma of the stomach are quite rare in infancy 
and childhood. There are but few cases on record. But as they are 
rarely suspected except in advanced age, and have occasionally been 
overlooked in the adult, it is advisable to watch for them. 

F. Intestinal Disorders. 
I. Constipation. 

The catarrhal and inflammatory diseases of the mucous mem- 
brane of the intestinal tract have so many common anatomical and 
pathological features that, for practical reasons and to avoid repeti- 
tion, I prefer to discuss them under the heads of their principal 
symptoms. Indeed, acute, subacute, and chronic catarrh (enteritis), 
cholera nostras, follicular enteritis, even membranous enteritis, are, 
to a great extent, varieties of the same process, differing only in 
individual acuteness, or extension, or in its localization in the epi- 
thelium, muciparous follicles, or lymph-bodies, or in innervation, or 
in the amount of microbic infection, which, as the intestine is 
relatively longer than in the adult, renders absorption of toxins 
much easier. That is why indican and acetone are readily found 
in the urine. 

The main symptoms observed in diseases of the intestinal tract 
are constipation (less frequent) and diarrhoea. 

The therapeutics of constipation depends on its etiology and its 
degree. In no case should the diagnosis be made without a thorough 
examination, which must in many be manual. The abdomen may be 
painless, but it is mostly inflated. Faeces come away in large lumps or 
in small and broken pieces. The liver and spleen may be displaced, the 
former turned in such a way as to protrude its edge and posterior sur- 
face. The abdominal veins may be enlarged, the appetite diminished ; 
vomiting is sometimes met with, occasionally also intervening attacks 
o.f diarrhoea which are the result of the irritation produced by the 
hardened fecal masses contained in the colon. 



340 DISEASES OF THE DIGESTIVE ORGANS 

An actual constipation should not be mistaken for an apparent one, 
which is observed in infants that have a small movement every two or 
three days only. The baby is emaciated, atrophic, not always fretful. 
In it the scantiness of defecation is the result of lack of food, and the 
alleged costiveness is speedily remedied by the furnishing of a sufficient 
quantity of appropriate nourishment. 

Among the foremost causes of constipation is mechanical obstruc- 
tion, brought on by cystic and other tumors, imperforation, hernia 
(pervious or incarcerated), dilatation of the colon, congenital muscular 
incompetency (general or local), intussusception and twisting of the 
intestine, or by a peculiar condition of the sigmoid flexure described 
by me in the Journal of Obstetrics of 1869. Cases of constipation 
depending on the undue length of the descending colon and on the 
multiplicity of flexures which compress one another and thus obstruct 
the passage are quite numerous in every physician's practice. These 
cases of constipation are apt to last up to the sixth or seventh year 
and require constant attention, but medicinal treatment should be 
avoided, unless it be demanded by intestinal autoinfection. The faeces 
may, in very bad cases, be so hardened and immovable as to necessitate 
their extraction from the rectum by means of the finger or a spoon. 
Now and then, in this, also in other varieties of constipation, the 
hard masses are felt in the abdomen, and have been mistaken for 
tumors. On no account should purgatives be given as a regular thing, 
but an enema should be administered daily for many years in succes- 
sion. At the above-mentioned ages the relation of the several parts of 
the intestinal tract to one another becomes more normal, and the neces- 
sity for mechanical interference ceases accordingly. 

An improper condition of food is a frequent cause of constipation. 
Excess of casein is relieved by diminishing its quantity, by replacing 
the milk of a cow by that of a wet-nurse, the white and heavy one of 
a wet-nurse by the thinner and more bluish one of another woman, 
or by reducing the amount of casein in artificial food to one per cent. 
or less. Besides, the milk thus reduced should be mixed with a gluti- 
nous (farinaceous) substance; oatmeal, to remedy constipation, is 
preferable to barley or any of the rest. Large amounts of starch must 
be avoided. Milk and artificial food will often lose their constipating 
effect by the addition of cane-sugar. Babies at the breast are fre- 
quently cured of constipation by the administration of one or two 
teaspoonfuls or a tablespoonful of water, or oatmeal-water, thoroughly 
sweetened, before each nursing. 

Many preparations kindly supplied by the ever- watchful and 
humanitarian trade contain large quantities of phosphates. They 



CONSTIPATION. MEMBRANOUS ENTERITIS 341 

are apt to pass mostly into the intestine undissolved and unabsorbed. 
So will large doses of bismuth. Thus constipation may follow their 
use. The treatment of such a case is plainly indicated; likewise of 
those which are the direct result of the administration of astringents 
and opiates. The omission of such medication is the first condition of 
a cure. 

The rise of temperature which occasionally accompanies uncom- 
plicated constipation, usually without a rise of the pulse (sometimes it 
is retarded), is seldom high. It is often relieved by the hardened 
faeces changing their place, always after evacuation of the bowels. 
If there be chills (rare), they mean sepsis and require active purga- 
tion. 

Constipation is often dependent on the partial absence or the 
viscid condition of intestinal mucus. This is so in fevers, now and 
then in chronic enteritis (chronic intestinal catarrh), mainly of the 
lower bowels; also when there is too large a secretion from the skin 
and (or) kidneys, and when too little water is introduced into the 
circulation. I have repeatedly emphasized the fact that most infants 
are given less water than they require. In membranous enteritis 
the large amounts of mucus discharged through many weeks or 
months, and sometimes years, are less frequently found in children 
than in hysterical (men or) women. That mucus is no longer viscid, 
but appears in the shape of membranes, sometimes in casts, and con- 
sists of nothing but mucus, with little pus, many leucocytes, and more 
or less traces of fibrin. In this condition also there is constipation, 
sometimes interrupted by diarrhoea ; the discharges, hard or loose, 
may be quite frequent, however. Moderate cases, with mucus as the 
main part of the discharges, are called mucous enteritis. Large injec- 
tions of warm water with one or two per cent, of sodium bicar- 
bonate should be made daily, at least once daily. Now and then a mild 
purgative (castor oil) is advisable. But the condition which is mostly 
found in neurotic children, or such as belong to a neurotic family, will 
not be relieved except through persistent attempts at improving the 
general condition by hydrotherapy and other general tonics. In a few 
cases occurring in more advanced years, to give the irritated, nervous 
colon a protracted rest, a right inguinal colostomy has been per- 
formed, with alleged recoveries. After a while the artificial anus 
was closed. 

Incomplete peristalsis resulting in costiveness may depend on a 
morbid condition of either the muscle, both of the intestine and the 
abdominal wall, or its innervation, like its reverse, — viz., excessive 
peristalsis or antiperistalsis, — which are both of nervous origin (Gus- 



342 



DISEASES OF THE DIGESTIVE ORGANS 



tavus Langmann, Festschrift*). Early rhachitis shows its effect in 
producing muscular incompetency; babies with regular evacuations 
after birth will become costive in their second and third months, and 
remain so although they are alleged to " look the picture of health." 
Not rarely rhachitis will make headway in muscles, epiphyses, and 
diaphyses, even in cranial bones ; at that time and afterwards, while 
the weight of the patient does not decrease, his skin feels soft and 
flabby, and the limbs and trunk are rotund though bleached. Indeed, 
there are many in whom constipation is the very first symptom of 
rhachitis. In all of them it is self-evident that constipation cannot be 
relieved permanently except by a thoroughly successful antirhachitical 
treatment. Sedentary habits of school-children have the same effect 
in producing constipation. It is relieved by change of habit, plenty 
of physical exercise, and additional fruit diet, but purgative medicines, 
given persistently, render these cases worse. The binding effects of 
chronic peritonitis, either general or local, must, as a rule, not be com- 
bated with purgatives ; a snug bandage round the abdomen gives sup- 
port and tone to the bowels, and an enema, given every day for months 
in succession, prevents accumulation and its consequences (dilatation, 
disorder of circulation, septic absorption). No massage. Universal 
emaciation and atrophy resulting in constipation have their own indi- 
cations, and chronic cerebral disease (hydrocephalus) may require 
such local and medical treatment as has been detailed above. 

In all forms of constipation in infants or children few medica- 
ments ought to be used. Honey, or sweet butter, or a teaspoonful of 
olive oil, given between meals, relieves many a case. An habitual drink 
of cold water after rising may have the same effect. As there is so 
often an excess of acid in the gastric and even intestinal contents, cal- 
cined magnesia has its twofold indication. It may be given in many 
small doses or a single large one which need not exceed five or ten 
grains (0.3 or 0.6) a day. Doses of a grain or two grains may be 
continued for many days and repeated from three to six times daily. 
Rhubarb acts well when combined with it for the purpose of over- 
coming protracted costiveness. Rectal injections may be given from 
the fountain syringe, the nozzle of which should be introduced beyond 
the two sphincters. In some cases it is desirable to introduce the 
instrument to a greater distance; an elastic catheter attached to 

* William B. Cannon (Amer. Jour. Physiol., vol. v., No. 5) proves that 
emotions may stop the movements of the small and large intestines; but that 
the colon (not the small intestines) has normally a period of peristalsis and 
antiperistalsis, each lasting five minutes, with a rest of five minutes, so that 
the whole process takes fifteen minutes. 



CONSTIPATION 343 

the nozzle may be used for that purpose, but the condition of the 
sigmoid flexure, detailed above, renders the introduction of the instru- 
ment beyond the very beginning of the sigmoid flexure a perfect illu- 
sion in many cases. It happens quite often that an elastic or flexible 
tube, when introduced to or beyond the third sphincter, bends upon 
itself and reappears at the anus. To facilitate the entrance of the 
liquid into and beyond the sigmoid flexure the injection should be 
made gently and slowly while the pelvis of the infant is raised. The 
nozzle must be smooth and not thin. 

To facilitate the downward movement of fecal masses and to 
stimulate peristalsis, friction and kneading (massage) may be resorted 
to. Kneading must be performed with the palm of the hand, gently 
and persistently ; or gentle thumping with the closed hand and fric- 
tion are best commenced on the right side and continued over the epi- 
gastrium and down the left side, in the course of the colon. Great 
caution and judgment must be used because of the frequency of local 
chronic peritonitis, which, when disturbed, causes subacute or acute 
exacerbations. 

Electricity has been used successfully when constipation was the 
result of insufficient peristalsis. E. Schillbach found that the several 
portions of the intestinal tract respond differently to the application of 
the faradic and galvanic currents.* The latter appears to have a 
stronger effect than the former. Local contractions result from the 
negative pole (cathode), peristaltic waves from the positive (anode). 
Thus, for the relief of chronic constipation depending upon incompe- 
tency of muscular action, the former ought to be applied to the interior 
of the rectum, the latter over the abdomen, along the colon. 

In the cases of persistent constipation depending upon an insuffi- 
cient muscular action of the intestine medication may now and then 
be required. I have treated a number of cases of the kind with 
nux and (or) physostigma, adding some purgative extract. A little 
boy with a decidedly rhachitical history (three years old) took three 
times a day a sixteenth of a grain (four milligrammes) of each — 
extract of nux vomica, extract of physostigma, and compound extract 
of colocynth — for many weeks in succession. But cases of the kind 
are, and should be, exceptional. As an occasional purgative, for the 
purpose of relieving the intestinal tract of indigestible and injurious 
masses, castor oil is probably the best and mildest ; a few grains 
calomel, or less, will act both as a purgative and an antifermentatr 
Compound powder of licorice will take the place of oil, when^ 

* See Meltzer. p. 270. 




344 DISEASES OF THE DIGESTIVE ORGANS 

latter is not tolerated or is objected to; also the fluid extract of rham- 
nus frangula or of rhamnus purshiana. 

Among the drastics, all of which are irritants, rhubarb and aloes 
are probably the mildest, and are tolerated a long time in succession. 
Of the salines, sodium chloride is the simplest. Its main action is 
osmotic; besides, it occasions thirst and thereby induces the inges- 
tion of a large amount of water. The continued use, however, of 
salines irritates the mucous membranes. The combination of sodium 
sulphate with magnesium sulphate and sodium chloride has a mild 
and happy effect. 

A frequent accompaniment of constipation is colic. Its causes are, 
besides constipation, fermenting food, gastro-intestinal catarrh, the 
presence of ascarides in large numbers, reflex spasm produced by cold 
feet and chilled skin, diminished tonicity of the muscular layers of 
parts of the intestine (in general anaemia and rhachitis during early 
infancy), mesenteric neuralgia (lead), and, finally, chronic peritonitis, 
which results in adhesions or such local changes in the walls of the 
intestine as will produce local contractions or dilatations. There may 
be many cases in which a diagnosis is difficult, but there is no such 
thing as " pseudo-peritonitis." Thus, as the etiology of colic varies so 
much, the treatment must vary in order to be rational and effective 
and adapt itself to the cause. Its symptomatic treatment will often 
require either an enema or a purgative medicine, antispasmodics or 
narcotics (assafcetida, opium) ; they are apt to give speedy relief. 
Gentle friction of the abdomen, the application of dry heat (flannel, 
hot plate, hot sand-bag), the administration of hot aromatic teas 
freshly prepared (fennel, anise, catnip, German chamomile), a few 
drops of essence of peppermint in a teaspoonful of hot water, or the 
injection into the rectum of large quantities of aromatic teas, at a 
temperature of ioo° F. or more, will do good; great care should be 
taken lest atmospheric air enter the bowel. 

2. Diarrhoea. 
Diarrhoea is always dependent on, or connected with, surface 
changes of the intestinal mucous membranes, from simple catarrh 
to ulceration. Catarrh may be localized, but is generally very exten- 
sive. It may descend from the stomach, ascend from the rectum and 
*olon, or originate in any part of the small intestines. 

The treatment of diarrhceal diseases depends in part on the locality, 
on the etiology of the individual affection. No " specific" treat- 
ever do good, not even the modernized stomach-pump stick- 
'itedly out of the coat-pocket of the delighted medical man, 




DIARRHCEA 



345 



who appears eager to emulate the midwife of our mothers with the rec- 
tal syringe under her arm as her emblem. 

The causes of diarrhoea are various. A predisposition is produced 
by the incompetent or defective condition of the mucous membrane 
in anaemia of long duration, rhachitis, scrofula, etc. Food in improper 
quantity or quality, mostly unsuitable artificial food, is among the prin- 
cipal causes ; but even mother's milk may give rise to it, as is proven 
by the fact that there are babies who, while falling sick at the breast 
of one woman, recover at that of another. Mothers who are sick or 
convalescing, or subject to very strong emotions, those who nurse too 
often, who suffer from tuberculosis or syphilis, who are pregnant, 
some when they are menstruating, and all anaemic persons secrete an 
improper milk. The colostrum furnished immediately after childbirth 
is apt to give rise to diarrhoea. Milk containing too much fat is the 
principal source of what has been described as " fat diarrhoea," by 
German authors mostly; that containing salts in superabundance, 
mainly in anaemia of the mother, is liable to produce the same effect. 

The amount of food introduced may be too large either absolutely 
or relatively; the latter when the secretion of gastric fluids is insuffi- 
cient, thus facilitating gastric fermentation in place of digestion ; 
or when the flow and activity of pancreatic juice, limited at a very 
early age, is still more interfered with by a diseased condition of any 
kind and fever of any description. 

The infant intestine is not controlled by emotional influences to 
the same extent as that of the adult ; but local irritation is a frequent 
cause of diarrhoea, and the organ is very sensitive to the diminution 
or increase of atmospheric moisture and heat. It is quite probable 
that the overheating of the general surface affects the blood, the 
duodenum, and the general nervous system similarly (though not to 
the same extent and with the same suddenness) to what is observed 
after serious burns. 

The mucous membrane with its lymph-vessels and follicles is 
easily irritated by such results and companions of fermentation as 
phenol, indol, skatol, and bacteria ; by the alkaline salts formed 
through the frequent (normal and abnormal) prevalence of acids in 
the upper part of the intestinal tract ; by the direct influence of pur- 
gatives, occasionally by even the very smallest doses of arsenic and 
mercurials, though, indeed, the latter are tolerated very much better 
by the very young than by the adult ; and by sudden exposure to a 
cold temperature. It is also liable to suffer long from the results 
of typhoid fever, dysentery, and occasionally from severe attacks of 
malaria. Protozoa are stated bv Quincke to be causes of chronic 



346 DISEASES OF THE DIGESTIVE ORGANS 

diarrhoea {Bed. kl. Woch., 1899, No. 47) ; amoeba coli is often found 
on ulcerations. 

Disturbances of the circulation depending upon diseases of the 
liver, lungs, or heart predispose to passive hyperemia of the intestine 
and to diarrhoea. Indeed, when it does occur in these diseases, it 
is an ominous symptom. In no case of intestinal disease ought the 
diagnosis to be considered complete or a prognosis ventured upon 
unless the liver, and particularly the heart, lungs, and kidneys, have 
been examined with great care. Uraemia sometimes causes diarrhoea 
without any apparent anatomical changes in the pale mucous mem- 
brane, at other times with catarrhal, ulcerous, or croupous changes 
depending — in part, at least — on the action of ammonium carbonate. 

The variety of causes suggest a number of different treatments. 
Disorders of circulation should be regulated while the local disease 
is attended to; ulcerations of the intestines are to be treated by some 
such method as has been suggested in previous remarks on dysentery ; 
the skin, if there be fever, should be kept cool by bathing or sponging ; 
the air-supply should be cool and plentiful. 

Most cases of intestinal catarrh (with or without gastric catarrh) 
and diarrhoea depend on the administration of improper food and 
the derangement produced by it. That should be changed imme- 
diately. When the process of fermentation is still limited to, or 
going on in, the stomach, or the stomach still contains injurious 
masses, these ought to be brought up. In such a case the sound 
judgment of the practitioner must decide whether emesis is still 
useful or whether the stomach ought to be irrigated and washed out. 
Most cases of " gastro-enteritis" are pre-eminently enteritis ; there- 
fore the assertion that the washing out of the stomach must not only 
take place in every case, but is the almost infallible remedy in the 
very worst class of cases, will have no other result than that of dis- 
crediting that useful procedure in those who are inclined to believe 
implicitly in the value of " new" methods and the pretentious claims 
of short-sighted enthusiasts. If we were to believe some of the loud 
talk of the journals, and the reporters' columns in the secular press, 
gastro-intestinal catarrh would soon be " one of the lost arts." 

In fact, the injurious element is in most cases beyond the reach 
of the stomach-pump; indeed, the latter cannot remove anything but 
what is dissolved or suspended ; the expulsion of large masses, curd 
particularly, through an elastic catheter is not always possible. 

The role played by bacteria in the stomach and intestines is surely 
great; the class of the schizomycetes is numerously represented alike 
in the healthv and the diseased intestine. Even within from four 



DIARRHCEA. BACTERIA 347 

to eighteen hours after birth there are large numbers of bacteria, 
cocci, bacilli subtiles, and bacteria coli communia (Escherich) in the 
remnants of digested milk; the latter microbe in the large intestines. 
How many are introduced into the stomach immediately after birth 
by the air swallowed by the newly-born cannot be determined. Be- 
sides those enumerated above, there is the bacterium lactis aerogenes, 
which is credited with the decomposition of milk-sugar into lactic 
acid, carbonic acid, and hydrogen, thus giving rise to most of the 
gases constantly present within the intestinal tract. 

The presence of immense quantities of micro-organisms, how- 
ever, proves nothing in regard to the etiology of diseases, for they 
are found in the healthy state as well, as also in those morbid 
conditions in which the cause of death cannot be attributed to the 
presence of parasites or to the usual pathological changes. Thus, in 
arsenical poisoning the intestines are swarming with saprophytes. 
To what extent bacteria, and which of them, are the actual causes of 
diarrhceal diseases, and of which and of how many of them, is still 
debatable, in spite of Baginsky's and Booker's labors. During lac- 
tation, in the young child, the upper part of the small intestine holds 
bacterium lactis aerogenes, the ileum and colon bacterium coli com- 
mune. During the summer diarrhoeas both varieties increase in num- 
bers and swarm over the whole intestine ; therefore in neither of them 
is there anything specific or etiologically important. In protracted 
cases of catarrhal enteritis leading to ulceration, according to W. 
Booker, streptococci are found in large numbers ; in more than half 
the cases proteus vulgaris is found, mainly in the stomach and the 
colon ; the putrid odor appears to depend on its presence. Both these 
microbes (mainly, however, the bacterium coli and the pneumococcus) 
may immigrate to the abdominal viscera, the lungs, the blood (not 
frequently), and the kidneys; thus, if they be causes of the original 
disease, establishing a local, distant (pneumonia, nephritis, pyelitis), 
or a general, constitutional malady (sepsis or furunculosis) as con- 
sequences. Or they are carried mechanically, causing pharyngitis, 
otitis, bronchitis, and broncho-pneumonia. To judge from the un- 
doubted occurrence of diarrhceal diseases by contagion ascending 
through the anus (soiled diapers, fingers of nurses, contact in insti- 
tutions), bacteria and their toxins must be credited with being more 
than companions, — that is, direct causes and sources of the local and 
general affections. 

The different forms of diarrhceal diseases are classed under dysen- 
tery by C. W. Duval and V. H. Bassett. They say, " We believe our 
findings justify us in the conclusion that the summer diarrhoeas of 



348 DISEASES OF THE DIGESTIVE ORGANS 

infants are caused by intestinal infection with bacillus dysenteriae, 
Shiga, and therefore are etiologically identical with the acute bacillary 
dysentery of adults. The cases studied, from which the dysentery 
bacillus was isolated, include examples of so-called dyspeptic diar- 
rhoea, of enterocolitis, and of malnutrition and marasmus with super- 
imposed infection" (Amer. Medicine, September 13, 1902). 

The intestine may be emptied either by purgatives or enemata ; 
the former act upon the whole length of the intestine, the latter upon 
its lower portion. Castor oil, so common in domestic practice, de- 
serves all the credit given to it. It acts mildly and speedily. The 
addition of opium is not wise; the latter may be administered after 
the former has exhibited its effect ; the action of the oil must not 
be inhibited by the sedative. In many cases a single dose of calomel 
(from one-half grain to six) answers better, being both a purgative 
and an anti fermentative. 

The surplus acids of the stomach — mostly lactic, acetic, and butyric 
— must be neutralized by sufficiently protracted treatment. Magne- 
sium and sodium salts must not be selected for that purpose, for 
they add to the diarrhoea. Calcium salts, the carbonate or phosphate, 
are preferable because they have no such effect, but the additional 
advantage of forming with the fat acid an insoluble salt which acts 
as a protection to the sore surface. Doses of about one or two grains 
(0.05 or 0.1 ) may be given every hour or two. Besides being an anti- 
fermentative in general, bismuth (the subcarbonate) binds hydrogen 
sulphide, and thus has a favorable effect in frequent doses of from 
a quarter of a grain to two grains or more. They may be admin- 
istered with or without the addition of opium. If they be given in 
liquid form, no syrups should be added to correct the taste, but rather 
glycerin, which has the advantage of not turning sour. The sub- 
gallate is credited with a still more constipating action and the 
salicylate with additional antiseptic effect. It is not so well tolerated 
as the subcarbonate. 

To combat the existing fermentation, antifermentatives may be 
given at regular intervals. Calomel, bismuth, alcohol, creosote, sodium 
salicylate, salol, naphtalin, resorcin, mercuric bichloride, and others 
have been eulogized. To take effect in the intestine, it appears that 
those which are not readily soluble in the stomach ought to prove 
more useful. Still, I feel positive that resorcin in doses of from a 
quarter to one-half of a grain (0.015 to 0.03) in solution, or as a 
constituent of a powder containing bismuth, chalk, or (and) opium, 
given every two hours, has rendered me the most valuable services in 
a great many cases. Of the two mercurials I prefer calomel by far, 



DIARRHCEA 349 

in doses of from a twentieth to a quarter of a grain (three to fifteen 
milligrammes) every few hours. The antifermentative effect of alco- 
hol in the dilution in which we are entitled to give it as a stimulant, 
though the sum total of a daily dose may be large now and then, is 
not great; sodium salicylate is less effective than any of the rest, 
creosote acts more vigorously in the stomach than in the bowels, salol 
is readily taken; naphtalin is objectionable to many because of its 
taste and odor. 

Opium, by its inhibitory effect on reflexes, diminishes hyperes- 
thesia, hyperperistalsis, and hypersecretion. The objections to its 
use in certain conditions in the diarrhceal diseases are theoretical 
only. Doses of from one-tenth to one-third of a grain (six to twenty 
milligrammes) of Dover's powder every two hours, in all sorts of 
combinations, act very well indeed, and may be considered indispen- 
sable when the above indications are to be fulfilled; but its time has 
mostly arrived only when the odor of the evacuation begins to be 
normal. That is why Vaughan and McClymonds (Festschrift) advise 
against the use of opium in cases of bacterium coli poisoning; they 
have observed that the condition got worse rather than better after 
its use. For that reason opium should be deferred until the alimentary 
canal has expelled its highly irritant poison. It is contained within 
the bacterial cell. That is why the bowels in their normal condition 
may carry untold undelivered bacteria coli without harm ; that is 
also why the path of the practitioner is beset with so many difficulties 
in forming his etiological diagnosis and his therapeutical indications. 
For, indeed, there are cases of " follicular enteritis" of a chronic 
nature, with malodorous discharges for weeks in succession, in which 
opium is not contraindicated. Bad odor and toxic infection are not 
identical. 

In acute cases, and when the stomach participates in the process, 
astringents, such as lead, tannin, gallic acid, alum, etc., are badly 
borne. In chronic protracted cases they will find their indication. 
Silver nitrate does better in many cases, from one-fiftieth to one- 
thirtieth of a grain (one to two milligrammes) in two drachms of 
distilled water (dark bottle) every two hours. In chronic cases only, 
coto, from half a minim to a minim of the fluid extract, will sometimes 
act favorably. Tannalbin, in daily doses of from four to fifteen grains 
(0.25 to 1.0) or more, as a powder or in mixtures, is among those 
modern medicines which are highly recommended (mainly for affec- 
tions of the lower bowels) by some observers, too highly by manu- 
facturers. Biedert recommends tannigen when the discharges are 
alkaline, tannalbin when they are acid. 



35o 



DISEASES OF THE DIGESTIVE ORGANS 



Of the stimulants, alcohol may be admixed with food. Bad brandy 
or whiskey contains fusel oil, which is a paralyzing agent. Whiskey 
is therefore preferable in America, because it can be obtained in 
greater purity for less money. It must not be administered unless 
diluted. Camphor is better borne than ammonium. It is easily taken 
when simply rubbed off with glycerin and suspended in mucilage 
(from one-fourth to two grains every one or two hours). The 
strongest nerve-stimulant of all is musk. Urgent cases of collapse 
require one or two grains (0.06 or 0.125) every fifteen or thirty 
minutes (best suspended in mucilage) until six or twelve grains have 
been taken. A very good stimulant in collapse is the injection into 
the bowels, through a good-sized flexible tube (catheter No. 12, Eng- 
lish) of hot water with not more than five per cent, of alcohol and 
one or a few drops of tincture of opium. In threatening cases of 
heart-failure strong coffee, hot or iced according to circumstances, 
by itself or in mixtures, may be used to advantage by mouth; hot 
in the rectum; or a subcutaneous injection of sodio-caffeine ben- 
zoate or salicylate, a few grains in the double quantity of water (1 
to 2) repeatedly. Cold tea may be tried in small doses, particularly 
in the chronic cases of older children. 

In acute cases of intestinal (or gastro-intestinal) catarrh with 
high temperature, applications of water of from 6o° to 70 F. to the 
abdomen will render good service. The cloth must be wrung out 
thoroughly, covered with rubber cloth and flannel, and changed when 
warm. Anaemic children and those with much pain require warm or 
hot applications, which may be preceded by a warm bath. Frequent 
injections of water of ioo° F. or more, with or without an antifer- 
mentative, such as thymol (1 to 1000 or 2000), answer well in most 
cases, not alone in rectal catarrh. In great debility or collapse the 
water ought to be from 105 ° to 11 2° F., and contain some alcohol 
and opium or (and) a teaspoonful of the tincture of musk. The 
addition of gum-arabic to the injection, or the use of glutinous decoc- 
tions (flaxseed) instead of water has a satisfactory influence. Starch 
injections have the advantage of adding to the nutrition of the body 
by the facility with which the colon changes amylum into dextrin, 
which will be absorbed. Part of the injected water will always be 
absorbed, fill the blood-vessels, and may prevent intracranial and 
other thromboses. Indeed, in many bad cases in which the cerebral 
symptoms of the so-called hydrencephaloid condition have made their 
appearance, or are imminent, frequent injections into the rectum of 
a few ounces of warm fluid contribute considerably to the restoration 
of circulation. 



DIARRHOEA. DIET 351 

In hot weather doors and windows should be kept open and the 
coolest place selected in the house or neighborhood, day or night ; for 
night air is preferable to no, or foul, air ; and sea air or country air, 
particularly at some altitude, is superior to city air. When in hot 
weather the body feels hot, it should be washed with cold or cool 
water, or water and alcohol (5 to 1), frequently. Cold feet must be 
warmed by flannels, hot stones, hot sand- or water-bags, and gentle 
friction, and well covered. 

The food supply must depend on the condition of the stomach 
and of the upper part of the intestine, and also on the rapidity of the 
peristaltic action of the latter. The complication of gastritis with 
enteritis contraindicates the introduction of food altogether. Absti- 
nence is better in cases of intense vomiting than the use of ice ; the 
latter may quiet the stomach for a while and feel pleasant, but it fills 
the stomach, which ought to remain at absolute rest, and excites peri- 
stalsis. Babies with an irritated stomach tolerate abstinence better 
than ingesta. The ubiquitous beef-tea ought to be avoided; its con- 
centration of salts is irritating. If in convalescence it be given at all, 
it should be mixed largely with barley-water or rice-water. 

In all cases of " summer" diarrhoea milk must be avoided. Bad 
cases forbid raw milk, boiled milk, milk in any and every shape, for 
days and longer. Its rapid fermentation contraindicates the smallest 
quantities, even in farinaceous mixtures. The absence of gastric juice 
(pepsin and hydrochloric acid) in the stomach of a feverish child or 
of one that is being drained of its fluids prevents the digestion of 
albuminoids. Even mother's milk is often not borne to any extent. 
When milk is again tried after a while, it ought to be done very care- 
fully: cow's milk thoroughly boiled, or sterilized with six times its 
volume of barley-water at first, the percentage of milk to be increased 
slowly. I repeat: cow's milk, ever so often boiled or sterilized, is 
still cow's milk. Milk may be replaced by the white of egg, which 
should be thoroughly mixed with barley-water, some salt added, 
and not more (cane-) sugar than is required to make the mixture 
palatable. During the course of a day and night the whites of from 
one to five eggs may be given according to the case and age. Severe 
vomiting and diarrhoea demand, as suggested, total abstinence for 
from two to eight hours or more. Afterwards, mucilaginous or 
farinaceous decoctions may be given in small doses at short intervals. 
A mixture which has rendered me very valuable services in the worst 
cases of vomiting and diarrhoea, after the period of absolute absti- 
nence was terminated, is about as follows: five ounces (150.0) of 
barley-water, the white of one egg, from one to two teaspoonfuls 



35^ 



DISEASES OF THE DIGESTIVE ORGANS 



of brandy or whiskey, some salt and cane-sugar ; a teaspoonful every 
five, ten, or twenty minutes according to circumstances. Mutton- 
broth may be added to the above mixture, or it may be given by 
itself, with the white of egg and a little salt. 

3. Tumefaction of the Mesenteric Lymph-Bodies. 

It is of frequent occurrence. Its results are very serious, though 
the non-absorption of chyle does not depend exclusively on the func- 
tional incompetency of the lymph-bodies. Simple inflammatory 
hyperplasia of the lymph-bodies can be more safely prevented than 
cured. Its original cause is mostly a diarrhoea of some form or 
another. The irritation of a mucous membrane leads always to that 
of the neighboring lymph-bodies ; thus a nasal catarrh, a stomatitis, 
a diphtheritic process, a pulmonary catarrh, produce secondary ade- 
nitis, and the mesenteric glands near an intestinal catarrh are soon 
congested and begin to swell. Cell-proliferation accompanies the 
changed circulation; when its original cause — viz., the hyperemia of 
the mucous membrane — has ceased, absorption of the newly depos- 
ited material will always take place in the same way that the swelling 
of the glands of the neck will disappear when a nasal catarrh is treated 
with cleansing and disinfecting irrigations or injections. As soon, 
however, as the newly formed cells have been transformed into firm 
fibrous tissue, the possibility of absorption becomes less from day to 
day. Thus, the prevention of mesenteric glandular hyperplasia con- 
sists in the immediate removal of a diarrhoea. Be it ever so mild, it 
is always a morbid process. Be its name ever so innocent (for in- 
stance, " dental"), and the prejudice in favor of letting it alone ever 
so strong, it leads to anatomical changes which may become perma- 
nent in the mucous membrane and the glands. When a diarrhoea 
has been protracted, it may safely be assumed that the lymph-bodies 
necessarily undergo chronic changes. Then the cautious adminis- 
tration of an iodide, preferably sodium, is indicated, in daily doses 
of from five to fifteen grains (0.3 to 1.0), according to the age of 
the patient, the severity of the case, and the probable duration of the 
process. It should be continued for weeks, and may then be replaced 
by three daily doses of from five to twelve minims of the syrup of 
the iodide of iron. When no iodide is tolerated, it may be substituted 
by iodipin (containing ten per cent, of iodine), of which from one- 
half to one teaspoonful may be given daily, in emulsion ; for inunc- 
tion, one part of iodipin with three of vasogen, or with two of lanolin 
and one of vaseline. Morbid processes of any kind in neighboring 



MESENTERIC LYMPH-BODIES. APPENDICITIS 353 

organs may cause glandular swelling. Adenoma of the liver in a 
girl of twelve led to (not adenomatous, but simply hyperplastic) 
tumefaction of the periportal lymph-bodies and to a very rapid devel- 
opment of ascites (Trans. Assoc. Am. Phys., 1897). 

Primary tuberculization of the mesenteric glands is quite rare; 
so is primary tuberculosis of the intestine, in spite of the fact that 
meat (very rarely) and milk containing the bacillus are known to be 
the occasional cause of tuberculosis of the bowels. Both are, as a 
rule, though by no means always, the results, or complications, of 
general tuberculosis, and in this way they, and tubercular peritonitis 
also, are not uncommon. Thus, the treatment of tubercular tume- 
faction of the mesenteric glands forms part of the measures under- 
taken for the relief of the symptoms of the general infection, and 
leaves but little hope. But there are cases in which the tubercular 
nature of the swelling cannot be doubted, that nevertheless get well. 
There are now on record a number of cases of peritoneal tubercu- 
losis in which laparotomy was performed, either through a mistaken 
diagnosis or purposely, and the lymph-nodes were found numerous 
and greatly enlarged, that recovered. Thus, even such cases afford 
no reason to pronounce a fatal prognosis. 

The conditions alluded to must not be mistaken for tumefaction 
of the mesenteric lymph-bodies from other causes (for instance, pri- 
mary lymphoma, the glandular enlargement of leucocythsemia or 
syphilis, or sarcoma which occurs primarily, or from carcinoma which 
is occasionally met with secondarily in young or older children). 
Lymphoma and sarcoma are positively improved by the protracted 
use of arsenic in increasing doses, such as are discussed on page 120. 
Syphilitic swellings require the persistent administration of active 
doses of both mercurials and iodides. 

4. Appendicitis. 
It is a very frequent disease in childhood, and much more so than 
acute colitis or typhlitis not attended by an affection of the appen- 
dix. There are, it appears, anatomical reasons for it. The appendix 
of the newly-born is one-tenth of the length of the colon, that of the 
adult one-twentieth (Ribbert). It continues to grow (Sokolow) to 
the thirteenth year, remains stationary until the twentieth, and then 
undergoes atrophy, so that at fifty its width is less than at birth. In 
the young its contents may be expelled by its contraction (Klebs), or 
are retained in the fcetus and in children with flabby intestines, and 
give rise to colic when the mucous membrane is thickened. Appen- 
dicitis from this cause must be frequent at that age. There is, besides, 

23 



354 DISEASES OF THE DIGESTIVE ORGANS 

much folliculitis in the young (rare after thirty years) ; that is why 
gangrene is frequent in early life. Absolute rest and very careful 
observation of the patient by a competent person are required. Even 
in the mildest cases the patient must use the bedpan and urinal, and 
under no circumstances be permitted to change his position un- 
aided. The disturbance of an incipient peritonitis by mechanical 
causes is a serious matter ; recent adhesions are very liable to be torn 
and give rise to new attacks. No purgatives must be given except 
a dose of oil in those rare cases in which no evacuation has taken 
place for some time, and when the accumulation of large quantities 
of faeces in the colon is certain or considered probable. In these 
cases, however, a large enema of soap and water given at once will 
mostly fulfil all the indications. Thus, I am not at all prepared to 
advise, with a few modern authors, to commence the treatment of 
appendicitis (and peritonitis in general) with magnesium sulphate 
or a large dose of calomel. The injection, however, first of a few 
ounces of olive oil, and afterwards of large quantities of soap and 
water, through a fountain syringe, is again indicated after a week or 
ten days. No stomach washing, no puncturing to establish a diag- 
nosis. Opium must be given freely by the mouth, rectum, or sub- 
cutaneously, in full doses, but discontinued, or its doses reduced, when 
there is tympanites. In almost every case ice applications should 
be made for days to the right hypochondrium, and warm applications 
after many days when the fever subsides. The food must be liquid 
and given in small quantities at a time. The patient must remain 
in a recumbent posture for weeks after apparent recovery, and be 
kept quiet even then, for an abscess may be capsulated and perforation 
may occur. If after a few days the fever increase and there be more 
exudate, the operation should not be deferred. If the mild symptoms 
remain unchanged for eight or twelve days, the operation should be 
performed. 

A positive diagnosis should be made early. Frequent previous 
pain in the same locality and intestinal disorders accompanying it, 
or a similar attack which occurred months ago, a very sudden csecal 
pain (McBurney's point) with vomiting (or without) a few hours 
or days ago, and illness with fever, perhaps the presence already 
of slight swelling, and the raising of the whole right lower ex- 
tremity by the unaided patient, while lying on his back (Meltzer), 
leave but little doubt. In many cases the locality of the pain is not 
conclusive ; it may begin on the left side, or in the transverse colon. 
When the diagnosis of appendicitis is established, to say, with a 
modern author (Tyson), that the surgeon should be called in to 



APPENDICITIS 355 

decide on the time of operation is rather rash. Of Biermer's one 
hundred and twelve hospital cases of all ages not operated upon, 
between the years 1874 and 1889, ninety-eight left well and nine 
" relieved." Relapses took place in seventeen, of which two died. In 
five many recurrences took place. These figures are very favorable, 
— too favorable, in my experience, — though the course is apt to be 
milder in children than in adults. Hawkins reports on two hundred 
and sixty-four cases with a mortality of fourteen per cent. ; of those 
which terminated in abscess twenty-six per cent, died, of those with 
peritonitis seventy-five per cent. But even the complication with 
general peritonitis need not be despaired of. R. Abbe (Med. News, 
May 29, 1897) concludes from a large array of such cases, his own 
included, that " the earlier the operation the better the prognosis ;" 
but " there still remains a chance for life if the period elapsing be not 
more than two and one-half days." 

In many acute cases with violent symptoms a timely operation 
alone will save the patient. To establish the indications for surgical 
interference in these cases is, however, rather difficult. Pulse, tem- 
perature, local pain (with or without pressure), and swelling require 
close watching. If the pulse goes up to from 120 to 140 and stays 
there, if after five or six days there be no improvement in the general' 
symptoms, in the fever and swelling (or either of them), or if the 
temperature of the body, after decreasing, rise again, I consider the 
indication for operation very urgent. A general rule, however, cannot 
be established. 

The indications for the time at which the operation is to be per- 
formed are not always easily found. Indeed, opinions still vary with 
reliable authors and surgeons — a great many of whom, in all coun- 
tries, have given the very closest attention and the very best thought 
to the subject — as to the proper time at which the operation ought 
to be resorted to. Some recommend and practise the operation as 
soon as perforation of the vermiform process has taken place, some 
favor procrastination until the beginning of the second week. Be- 
sides, there are those who object to any operation when universal 
peritonitis has set in, and those who perform laparotomy in the 
same class of cases. In a number of instances the time of the opera- 
tion depends on the condition of the patient; immediately after the 
perforation of the gut collapse is sometimes so great as to render 
surgical interference absolutely inadvisable. In these ice, opium, 
and stimulants are required to bridge over the imminent danger until 
the operation can safely be performed. I have seen such cases in 
which it was considered positively fatal at first, and proved successful 



356 



DISEASES OF THE DIGESTIVE ORGANS 



a week afterwards. There is no class of cases in which the responsi- 
bility of the medical man is greater and full knowledge and keen 
judgment are more urgently demanded. Not every case terminates 
in suppuration. In some there is a great deal of inflammatory exuda- 
tion. In them the protracted use of potassium or sodium iodide, 
lanolin ointments of the same, and occasional vesicatories will render 
good service. I have known many who had repeated attacks extend- 
ing over years, and finally got practically well. 

Still, there remain the results of the inflammation, — cicatrization, 
shrinking, adhesions, and the constant danger of a relapse. If those 
cicatrices and the appendix were removed, how much safer it would 
be! The responsibility of advising an operation for the purpose of 
removing the appendix of those who have suffered from repeated 
attacks in the intervals is great, that of not advising it is very much 
greater. Of thirteen children of Broca operated on for that purpose 
after recovery from one of the attacks, — that is, elective treatment 
between attacks, — all got well. Of seventy-two operations during 
the attacks, however, thirty-five per cent, died ; of five children whose 
appendix was removed during the operation for an acute attack, three 
died. Sonnenburg lost one case in one hundred and seventy-nine 
interval operations, Kummel none in one hundred and four, and the 
experience of all our American operators is equally favorable. The 
practice of performing interval operations is becoming more and 
more rational and successful. 

The indication for the operation in acute cases and the selection 
of the time for its performance are, perhaps, apt to be influenced by 
the observation — in New York City — of two facts : first, no matter 
what its unknown cause or causes may be, appendicitis is becoming 
more and more frequent; secondly, it is becoming more septic. In 
emergency cases, in the hands of the most skilled operators, many 
cases have died of sepsis soon after the operation, though it was not 
much delayed. That observation is liable to encourage the very 
earliest interference in acute cases. 

After recovery, purgatives must not be given for a long time ; but, 
as a matter of precaution, warm enemata should be administered 
every day. 

5. Paratyphlitis. 

This name refers to local inflammation, exudation, and suppura- 
tion which have nothing to do with the vermiform process, but with 
the copious connective tissue between the bones of the pelvis and 
the colon, which at that place is not covered by peritoneum. 

Such abscesses are sometimes the result of trauma; not infre- 



PARATYPHLITIS. INTUSSUSCEPTION 357 

quently of pelvic abscess ; of inflammation of the psoas ; of caries of 
the vertebrae; sometimes no cause can be found, even after it termi- 
nates in recovery. They will develop rapidly and some become very 
large. Sometimes pints or quarts of pus will either be discharged 
spontaneously or be removed by incision. Still, it is not always sup- 
puration that results from the inflammatory process in the connective 
tissue, but exudation and thickening only. When these happen, the 
treatment consists in the internal use of the iodides and the applica- 
tions of ointments of iodoform or iodide and lanolin, or of iodoform 
collodion (1 to 8 or 10) several times daily; cold-water applications 
which are kept up until they become warm ; or sometimes warm poul- 
tices, particularly in the cases of very anaemic children. 

6. Intussusception. 
Twenty-five per cent, of all the cases of invagination or intussus- 
ception of the bowels occur in the first half-year of life (two-thirds 
of them between the fourth and sixth months) and fifty-three per 
cent, before the end of the first year.* Thus, a knowledge both of 
the condition and the means to remedy it is essential to the family 
physician. The only successful treatment consists in the reposition 
of the intestine. When it has been accomplished the relief obtained is 
immediate. The vomiting, anxious expression, pallor, and collapse 
improve instantly, the little patient goes to sleep, and soon takes food. 
In the commencement of my practice, when an invagination extended 
down to the rectum I employed large sounds for the purpose of re- 
ducing the invaginated mass, but I have almost invariably found the 
case to be worse afterwards, because the sound will crowd the parts 
upon one another. I also used to blow air into the intestine through 
a long tube by means of bellows ; and in order to make the supply 
more regular I availed myself, forty or more years ago, of an appa- 
ratus for the production of carbonic acid gas. After that time, when 
the siphons with carbonic acid and mineral waters were invented, 
I used them for the purpose of filling the intestine more or less slowly 
with both gas and water. All these measures have proved successful 
in occasional cases. What has rendered me better service, however, 
is the following simple plan. The baby is turned on its belly, the hips 
are raised, and the abdomen gently supported by a soft pillow. The 
mouth and nose, being the lowest parts of the body, must be protected. 
The baby is anaesthetized with chloroform, and warm water is poured 
into the rectum with but little pressure, not from a height of " four- 

* See my Intestinal Diseases, p. 242. 



358 DISEASES OF THE DIGESTIVE ORGANS 

teen feet." This is important, for the intestine is no iron pipe subject 
to the laws of hydrostatics only. The injection is frequently inter- 
mitted, while the anus is closed by the finger. At the same time the 
abdomen, in the direction from below upward, is gently kneaded and 
its contents moved about. 

In not a few cases in the course of the last twenty or thirty years 
I have seen immediate result from this treatment. When reduc- 
tion has been completed, the baby must be kept absolutely quiet, take 
opium, now and then a rectal injection of chloral in solution, and 
wear an abdominal bandage just tight enough to steady the bowels. 
Relapses are not at all uncommon; probably it was a case of fre- 
quently relapsing intussusception in which Knaggs operated after 
forty-four days (London Lancet, April 24, 1891). 

In adults, Kussmaul reports favorable results from washing out 
the stomach. When the simple measure which I propose is un- 
successful after a number of trials, laparotomy should be performed. 
The successful cases of laparotomy are becoming more numerous, 
sufficiently so to justify the operation as the only means that promises 
a favorable result in irreducible cases. The late Henry B. Sands was 
one of the first who saved a baby of six months by this operation; 
at present the number of reported (and not reported) cases, both 
successful and unsuccessful, is very great. The latter should not 
count to the same degree as the former. All those who were saved 
by the operation would have died without it. Pitts (London Lancet, 
June 12, 1897) saved six out of seven consecutive cases. It is 
necessary to operate in time; for at best, laparotomy, in these cases, 
has its serious difficulties, and prolonged abdominal manipulations 
are not borne by infants. 

At an early period all the tissues involved are hypersemic and soft, 
with a tendency towards gangrene. In a child of eight weeks, on 
whom I operated, it took me ten minutes to separate the parts from 
one another, although I had the invagination, measuring six or seven 
inches, outside of the abdominal cavity. This delay was due to the 
softness of the tissues, the close impaction of the three layers, and 
the presence of a large amount of mesentery in the mass. Besides, 
the field of operation is very small and the difficulty of returning the 
intestine into the abdominal cavity very great. 

7. Helminthes. 
The medicines available for dislodging intestinal worms are all 
strongly irritant. They must not be given unless the diagnosis has 
been made positive. It is better that the diagnosis of a gastritis, 



HELMINTHES 359 

enteritis, or meningitis, when present, should be made by the medical 
man than that the child should be punished for his carelessness or 
ignorance. Before taking anything to expel taenia, a child ought to 
be in fair general condition. Moreover, its own taenia, the medio- 
canellata, is the most difficult to dislodge. The best time is when 
proglottides are seen in the movements. Moderate abstinence for 
days, at least for one day, and a purgative (castor oil) ought to 
precede the administration of drugs. The parasite must be expelled ; 
for though the symptoms may not be urgent, some day there will 
come either local or reflex disorders, possibly attended by danger. 

Spontaneous emigration will be noticed occasionally, but it should 
not be waited for. After the successful termination of the treatment 
the intestine should be allowed to rest. The plainest diet, such as 
milk, strained farinacea, and peptones, is indicated for days. 

I have administered a great deal of kamala, sometimes from ten 
to fifteen grammes (a quarter to one-half of an ounce), during one 
hour, early in the morning; the breakfast (milk) to be postponed 
for two hours. The effect was not uniform and often negative. It 
was improved by giving a dose of from twenty-five centigrammes to 
one-half gramme (four to eight grains) four or five times daily, for 
ten days or more, previous to the larger dose. A few hours after the 
larger dose castor oil ought to be given. 

Kousso, from four to fifteen grammes within two hours after the 
required preparation, to a child of from two to ten years. 

Ethereal extract of filix mas has proved most successful in my 
hands. A small child may take one gramme (fifteen grains) in an 
aromatic mixture, or in one or more capsules, within one early morn- 
ing hour. Four grammes are tolerated and required by a child of 
seven or eight years. The oleoresina aspidii of the Pharmacopoeia 
seems to act differently when purchased at different places. As the 
whole procedure of expelling a taenia is no trifle, it is worth while to 
be very careful in the preparation selected. 

Pelletierin tannate is given in doses of one or three decigrammes 
(one and a half or five grains). I have but little experience with it. 
It is obtained from cortex punicae granatum, which was (and is still) 
given as a decoction, but is too disagreeable and sometimes dangerous 
a mess for a child or infant. 

For the removal of ascaris some general preliminary treatment like 
the above should precede medication ; at least, the bowels ought to 
be moved gently. The powdered semina cynae (santonicae), or flores 
cinae, one gramme (fifteen grains) or more, mixed with a syrup, and 
followed by castor oil, will work well, but is very unpalatable. San- 



360 DISEASES OF THE DIGESTIVE ORGANS 

tonin, which is obtained from it, works as well and more pleasantly; 
from one to six centigrammes (one-sixth to one-half or one grain) 
several times a day, with a purgative such as magnesia, calomel, or 
jalap. The latter addition is desirable, inasmuch as now and then 
poisonous symptoms may appear. Older children will complain of 
" xanthopsia," yellow vision. Sometimes the urine and conjunctivae 
are yellow. 

As the oxyuris vermicularis (pin- worm) is frequently found in the 
rectum or its neighborhood, the internal administration of drugs will 
not relieve the local itching. Vaginal catarrh, resulting from the 
immigration of the worm, must be treated locally. The worm is 
removed by a small piece of blue ointment introduced into the rectum, 
or by rectal injections of vinegar and water (i to 3 or 4), of corrosive 
sublimate (1 to 1500 or 6000), or of decoctions of onions or garlic. 
It is difficult to dislodge, as it originally inhabits the colon and even 
the small intestine, and is within reach only after descending into the 
rectum. The rectal catarrh and tenesmus are best treated with warm 
irrigations of saline solution, or of starch-water, or of bismuth sub- 
carbonate suspended in water or starch-water. 

Anchylostoma duodenale has attracted a great deal of attention of 
late, and may become of more practical importance to us when the 
numerous blessings of emigration from the parts where the worm is 
indigenous go on as hitherto. 

The male is from six to ten, the female from ten to eighteen, milli- 
metres in length (one-third to one-half inch). The mouth is bell- 
shaped; there are two dental prominences above and four below. 
Particularly the female is thus characteristically endowed, so that it 
sucks and bites at the same time. Eggs, smaller than those of ascaris, 
are found in the fasces of the patient. The parasite is found in large 
numbers among the Italian workmen of the St. Gotthard tunnel, the 
tile laborers of the Rhenish provinces, and the Hungarian miners and 
their children. The causes of its presence are the muddy water 
they drink, which is filled with the ova, and the clay they work in, 
which contains the larvae. We now find it in the United States, 
mostly in the emigrant population. The general symptoms are very 
severe and dangerous, — debility, pallor, utter exhaustion like that of 
pernicious anaemia, and relative diminution of red blood-cells. This 
" Egyptian chlorosis" was explained by Griesinger, by the presence 
of anchylostoma, as early as 1854. Besides, there are pain in the epi- 
gastrium, constipation, mucous and bloody discharges, sometimes real 
hemorrhages and dyspncea. 

Anchylostoma duodenale requires santonin, thymol (adults should 



HERNIA 361 

take from two to ten grammes daily), and principally extract of filix 
mas. It would not enter the digestive organs if the water were boiled 
and filtered before drinking. Anguillula intestinalis is often found in 
its company and probably adds to its dangers. 

8. Umbilical Hernia. 

It is of very frequent occurrence in the infant, but seldom attended 
by danger. Incarceration takes place very rarely; still, Treves and 
many others have reported successful operations for such accidents. 
As there is a predisposition to the development of this variety of 
hernia, so there is a tendency towards spontaneous recovery. The 
round umbilical aperture will normally change after a number of 
months, or even a year, into a narrow fissure, more fat will develop, 
the muscles will become stronger, and then the intestine will be re- 
tained within the abdominal cavity. To accomplish this still more 
certainly, it is desirable to retain the contents of the hernial sac inside 
the abdomen. For this purpose the common forms of trusses are una- 
vailing. Strips of adhesive plaster serve very much better, but in most 
cases they are objectionable because they irritate the sensitive skin of 
the baby. An adhesive plaster (" Dieterich's"), containing from ten 
to twenty per cent, of zinc, does not irritate and answers the purpose. 

Whatever application is made to the hernia directly must be larger 
than the aperture. It should not be too hard. Linen compresses 
and those of woven lint, plates of cork covered with linen or lint, may 
be applied and held in position by means of a bandage. A knitted 
one will suit better than the ordinary one of linen, cotton, or flannel. 

9. Inguinal Hernia. 

In the newly-born or the very young it is apt to disappear spon- 
taneously; when, however, it depends on or is complicated with 
phimosis, circumcision should be performed to prevent the straining 
caused by it. Constipation must be overcome. When the short and 
straight inguinal canal becomes, in the course of a few years, longer 
and more oblique and the amount of fat goes on increasing, the rup- 
ture may disappear ; but all these predisposing factors never succeeded 
in effecting a cure by themselves. This is accomplished only when 
the hernia is retained inside the abdominal cavity completely and con- 
stantly by means of a truss, which must be worn for years. It must 
not be removed except when the baby is sleeping quietly. Trusses are 
uncomfortable in the beginning, and give rise to cutaneous irritation, 
particularly under the influence of urine. So much the more is it 
necessary to keep the truss clean, and always to select one which fits 



3 62 DISEASES OF THE DIGESTIVE ORGANS 

exactly without exerting too much pressure. If these mechanical 
means do not effect a cure after a few years, or when parts of the 
contents prove irreducible, the radical operation (Bassini, Kocher) 
or a new procedure devised by George R. Fowler, which consists in 
intraperitoneal displacement of the spermatic cord and obliteration 
of the internal ring and inguinal canal (N. Y. Polyclinic, July 15, 
1897), will save the patient much discomfort and remove the danger 
of a possible strangulation. A similar operation is recommended by 
Nelaton and Ombreville (Lyon Med., August 1, 1897). Lanne- 
longue's method of injecting zinc chloride solutions into the tissue 
should be recommended as little as the same method applied to tuber- 
culous joints or to spondylitis. 

Hernia is easily reduced into the abdominal cavity, in most in- 
stances, by gentle pressure while the legs are raised, sometimes best in 
a warm bath or under the influence of an anaesthetic; but there are 
on record quite a number of cases in which incarceration and strangu- 
lation required operative interference. The operation should not be de- 
layed after reduction, under the influence of an anaesthetic, has proved 
impossible. The mortality after the operation does not seem to be 
greater in children or infants than in adults. An instance of a success- 
ful operation on a case of strangulated femoral hernia, which occurred 
in a girl of eleven years, has been reported by St. Germain, also by 
Dowd (Arch. Ped., May, 1897) an( * others. Rees succeeded in re- 
ducing an inguinal hernia by aspirating from the intestine a quantity of 
turbid liquid. An exceptional procedure of the kind, however, must 
not be recommended for general adoption. If strangulation is old, 
taxis should not be attempted ; the less so, as the last few years have 
proved the almost uniform success of the operation. 

10. Catarrh of the Rectum. 
It behaves very often like a merely local disease. Indeed, it may 
occur as the result of a local irritation of the anus (scratching, sitting 
on muddy stoops), of oxyuris, of foreign bodies, or of hardened faeces. 
The immigration of bacteria through the anus was discussed above 
(p. 347). In all these cases the treatment should be directed to the 
cause, which must be removed. Warm injections of water, flaxseed 
tea, or starch decoction (with a little opium in tenesmus) are sufficient. 
Real proctitis, leading to ulceration (other than dysenteric) or fibrous 
hyperplasia, is an infrequent result. But it may occur ; the infiltration 
may become copious and lead to an invasion of the surrounding cellu- 
lar tissue. This periproctitis gives rise to abscesses, and often to fis- 
tula, either external or internal, complete or incomplete. These, as well 



THE RECTUM. CATARRH. PROLAPSE 363 

as the periproctitic abscesses due to pyaemia, to sepsis, or to the severe 
form of typhoid fever, require an early and large incision and careful 
antiseptic after-treatment. 

11. Prolapse of the Anus and Rectum. 

It is the consequence of catarrhal and inflammatory irritation and 
softening. It may follow chronic catarrh and dysentery. It is pro- 
duced by debility of the sphincter, which is often congenital, or some- 
times the result of neighboring diseases ; also due to drastic purgatives, 
or to constipation with the incidental straining; it first appears as 
a mere ectropion of the mucous membrane. Straining, resulting in 
prolapsus, is also produced by the presence of polypus or worms in 
the rectum, by stone and catarrh of the bladder, and by phimosis. A 
predisposition arises from the peculiar shape of the rectum in the 
young. It is straighter, inasmuch as the sacrum is not so concave as 
it is in the adult. 

The temporary reduction of the prolapse is readily accomplished, 
particularly in those many cases in which the sphincter is feeble, but 
the intestine will come down again. Attention must be paid to defeca- 
tion. The children should not be allowed to strain. Thus the cham- 
ber, if any be used, should be placed in such a position, and raised 
to such an extent, that the feet cannot touch the floor, or the child 
must not be permitted to sit up during defecation. * 

Many applications have been devised to retain the rectum inside. 
Adhesive plaster has been used as best it could be, and a number of 
instruments have been invented for the purpose of retaining the rectum 
in position, while leaving an opening for the passage of the faeces. 
They have been made of hard rubber, lead, and other materials. Some 
have used a tampon and others a compress to hold the nates together ; 
but a tampon will certainly dilate the paralyzed sphincter more than 
it was before. Curling confines his efforts to compressing the nates. 

The main attention should be paid to the treatment of constipation 
or diarrhcea, local catarrh, rectal worms, polypi, stone in the bladder, 

* Hippocrates makes the following remarks on this subject: "In children 
suffering from stone, and protracted genuine dysentery, the rectum is apt to 
protrude. It should be pressed in with a soft sponge, and touched with a 
snail., Then the patient should have his hands tied, and be suspended a short 
time, and thus the rectum will slip in. If it comes down again, a band should 
be placed around the loins ; a bandage must be attached to this, and the rectum, 
after being moistened with a decoction of lotos, be replaced with a soft sponge. 
Also, the intestine must be washed with this decoction and the bandage carried 
up between the legs to the umbilicus. During defecation the baby must sit with 
extended legs upon the feet of the mother, its body leaning against her knees." 



364 DISEASES OF THE DIGESTIVE ORGANS 

phimosis, and all the causes of straining and prolapse which have been 
enumerated above. 

But there are direct indications. Astringents have been used locally 
in the form of injections; principally alum and tannin, in solutions of 
one or two per cent. Ice has been applied locally, and injections of 
from half an ounce to an ounce of ice-water may be used with advan- 
tage three or four times a day. 

One enema must be given daily for the purpose of emptying the 
bowel and thus avoiding the possible straining. 

In most cases there is considerable swelling, sometimes real hyper- 
trophy of the mucous membrane and of all the tissues. Swelling and 
hypertrophy must be reduced. A part of the hypertrophied tissues 
has been excised. Caustics have been used; for instance, silver 
nitrate. It should be carefully neutralized immediately after the appli- 
cation by sodium chloride in solution. Concentrated nitric acid has 
been employed for the purpose of destroying some of the superfluous 
tissue. The best remedy, however, for this purpose is the actual cau- 
tery. It should be applied either in long welts or strips or at half a 
dozen or a dozen points. It matters not whether the galvano-cautery, 
or Paquelin's thermo-cautery, or the common actual cautery is selected. 

For the purpose of strengthening the sphincter, I have used fre- 
quently, for dozens of years, an ointment consisting of extract of nux 
vomica, one part in ten or fifteen parts of fat, to be applied to the 
lower part of the rectum from three to five times a day, or every time 
the bowel protrudes. The internal administration of strychnine is of 
very little avail, but that of ergot is serviceable. The subcutaneous in- 
jection of strychnine (sulphate, from one-sixtieth to one-thirtieth grain 
dissolved in water, once daily) in the neighborhood of the sphincter is 
beneficial, particularly when supported by the action of the inter- 
rupted electric current, which may be applied for a few minutes once 
or twice every day. Rational treatment is required for the constitu- 
tional causes of debility and emaciation (rhachitis, tuberculosis). 

12. Fissure of the Anus. 
It is by no means rare in infants and children, particularly in the 
latter. It gives rise to symptoms similar to those encountered in 
adults : severe pain during defecation, tenesmus, dysuria. Many cases 
of alleged flatulency and colic, and excruciating screaming spells, 
are due to fissure. The more severe form follows a direct injury by 
foreign bodies, hard faeces, etc. ; a mild form is due to slight erosions 
and ulcerations, the rhagades of congenital or acquired syphilis, or the 
sores made by erythema, eczema, or herpes, and by vulvo-" vaginitis." 



FISSURE OF THE ANUS. POLYPUS OF THE RECTUM 365 

The mildest form is that which is found on a very loose and dilatable 
anus. This yields readily to a mild local treatment of the sore with a 
solution of silver nitrate (1 to 250 or 500). Cases depending on 
syphilis require both general and local treatment; vaginal catarrh 
(colpitis, not "vaginitis") must be stopped and eczema healed. 

The treatment of the severe form has consisted in the relief of 
occasional diarrhoea, and that of the more frequent constipation by 
enemata and mild purgatives ; in the application of astringents, such 
as lead, copper, zinc, or alum ; or of caustics, such as the solid silver 
nitrate (Esmarch) or nitric acid. This treatment is painful and 
tedious. Boyer advised incision through the whole of the sphincters. 
The open wound, however, which is kept clean with difficulty, may 
bleed and give rise to ulceration or sepsis. The proper treatment con- 
sists in dilatation of the sphincters. Josseline directs it to be gradual, 
thereby protracting uncertainty and pain. The best and speediest 
method, however, is forcible and instantaneous dilatation, without or 
with anaesthesia. The operation takes so little time that it is hardly 
required, except in very puny or convulsive infants or children. The 
introduction of two fingers of the same hand is rarely sufficient ; three 
or four do better, or the thumbs of both hands. The easiest way is to 
use the two index-fingers for pulling; a sufficient dilatation is recog- 
nized by the distinct sensation that the muscular fibres have given 
way. The external wound is trifling and but superficial. There is 
rarely any bleeding, which will stop under the application of ice or a 
sterile tampon. Two or three warm rectal injections of salt water 
or starch-water should be made daily for some time. 

In the rare cases of fissure and polypus combined the treatment 
must be directed to both. 

13. Polypus of the Rectum. 
They are tumors from the size of a pea up to that of a cherry or 
hazel-nut, or more. They are single or numerous, quite soft, or more 
frequently of greater consistency, composed mostly of cells or cellular 
tissue, quite vascular, and contain often a harder adenomatous nucleus 
and a Lieberkiihn gland embedded in them. They are either peduncu- 
lated or sessile, on a broad base. They are often found in many mem- 
bers of a family, and (F. Huber) frequently connected with adenoids 
of the naso-pharynx. They are sometimes found between the two 
sphincters, mostly above and near the inner sphincter; not infre- 
quently, however, all over the middle portion of the rectum, sometimes 
quite near the " third sphincter," and very rarely in the caecum (Vajda 
in Jahrb. f. Kinderh., vol. 1.). 



366 DISEASES OF THE DIGESTIVE ORGANS 

Among - the symptoms we occasionally meet with abnormal defeca- 
tion (constipation, diarrhoea, or both in alternation), sometimes with 
enteralgia or tenesmus, and frequently a discharge of mucus or of 
blood. Tenesmus is found about polypi when seated near the internal 
sphincter or between the two sphincters. Blood is seldom mixed with 
mucus, mostly quite clear, from half a teaspoonful to a teaspoonful, 
sometimes more, so that the constant repetition of these small hem- 
orrhages is sufficient to result in anaemia, but also to establish the 
diagnosis. The tumor is often pushed into or through the anus during 
the evacuation of the bowels. 

The treatment consists in the removal of the tumor by means of 
the cold snare, by the galvano-caustic snare, by pincers or the fingers, 
or by ligature. The latter is easy of application in all cases in which 
every movement of the bowels results in rolling out the growth like 
a foreign body. In these many excursions a polypus with a thin 
pedicle is often removed spontaneously. When that occurs there is 
hardly a show of blood. Indeed, there is seldom much bleeding after 
removal. It is true that some writers report the occurrence of hem- 
orrhages ; but in infants and children, with whom varicosities of 
the blood-vessels are exceedingly rare, I have never seen a hemorrhage 
of any account after breaking the pedicle with my finger in the rectum. 
The latter is very accessible indeed to an index-finger of moderate 
size. 

Sessile polypi do not give rise to urgent symptoms, and some- 
times are not easy to find. The astringent injections which are to 
remove them should be mild. Solutions of one per cent, of alum, 
injected several times daily, will be found sufficient, or a two-per-cent. 
ointment, or a suppository. Bad cases require the speculum and 
scraping, with an antipyrin solution of fifteen or forty per cent., or 
the actual cautery to stop bleeding. 

G. The Liver. 

The diagnoses of alleged diseases of the liver are more numerous 
than its diseases. Primary affections are rare. Enlargement is fre- 
quently assumed to exist when the size is normal. In the foetus and 
infant the liver is proportionately large. At two weeks of age (Birch- 
Hirschfeld) it amounts to 4.2 per cent, of the body weight, at six 
months to 6.1 per cent., at one year to 5.8 per cent., at two years to 4.3 
per cent., at three years to 4.7 per cent., at four years to 4.8 per cent., at 
five years to 4 per cent., at six years to 3.5 per cent., at nine years to 
4.4 per cent., at ten years to 3.2 per cent., at twelve years to 3.8 per cent. 
Thus there is a gradual diminution, with but few exceptions. Its 



THE LIVER. ENLARGEMENT. PTOSIS 367 

size in the very young appears still larger because its lower part is 
not covered by the ribs (which in the young are placed more hori- 
zontally) as it is in the adult. Besides, the tympanitic intestines 
encroaching upon the liver from below and behind, and the rhachiti- 
cal contraction of the chest-wall, if present, render a much larger sur- 
face of the organ accessible to percussion and palpation. Thus, actual 
and primary enlargement is not a common occurrence. Secondary 
enlargement, however, may depend on constitutional — either chronic 
or acute — disorders, such as alcoholism, syphilis, leucocythaemia, 
chronic tuberculosis, suppuration of bones or glands (amyloid degen- 
eration, together with that of the spleen and of the kidneys), malaria, 
or typhoid fever. The therapeutics of these kinds of enlargement 
depends, therefore, on the character of the different causes. A case 
of multiple adenoma of the liver in a girl of twelve years was published 
by me in the Trans. Assoc. Am. Phys., 1897. Enlargement of the 
liver should not be diagnosticated when the organ is merely dislodged 
downward {floating liver, hepatoptosis). It may be primary, or sec- 
ondary to emphysema of the lungs, rhachitis of the chest, etc. In very 
rare cases its position may be so changed that the diaphragmatic sur- 
face looks outward, to the right side. Ptosis requires proper support 
by an abdominal bandage, or by strapping with broad adhesive strips 
(Achilles Rose). 

Another series of enlargements is that which results from changes 
in the circulation. Diaphragmatic pleurisy of the right side may con- 
strict the vena cava inferior and thereby lead to hypertrophy of the 
liver, ascites, anasarca of the lower extremities, and death. Pneu- 
monia in its acute stage impedes the hepatic circulation, temporarily 
mostly; when it is chronic, the consecutive hyperemia may lead 
to hypertrophy; the same effect may be produced by the persistence 
of pleural effusions on either side. Persistent obstruction of bile-ducts 
may have the same effect. More frequent yet is the secondary hepatic 
enlargement of heart disease, not so much in the congenital form, 
in which the amount of blood is greatly reduced by the low state of 
general nutrition, as in acquired (mostly rheumatic) endocarditis, 
but much more so in acute and chronic myocarditis. Indeed, rapid 
swelling of the liver will confirm the diagnosis of cardiac disease in 
the myocardium. A chronic perihepatitis with a thick and exten- 
sive exudate (" Zuckerguss") depending on pericarditis or right side 
pleuritis was described by Curschmann. It is independent of changes 
in the liver. A congenital induration of the liver, independent, how- 
ever, of perihepatic alterations, and due to portal changes, was de- 
scribed by Pick. Pericardial obliteration is frequent in both forms. 



368 DISEASES OF THE DIGESTIVE ORGANS 

The number of such cases increases with every year of life; indeed, 
children of eight or ten years with chronic valvular diseases and 
consecutive enlargement of the liver are frequently observed. Myo- 
cardial alterations are also very frequent. Thus, the treatment of 
hepatic disorders is that of the primary disease rather than of the 
secondary changes. 

Fatty infiltration of the liver is, in the very young, not often com- 
plicated with much increase in size ; for to a certain extent it is 
normal. But, in ill nutrition, protracted diarrhcea, to which the ten- 
dency is greater on account of the absence of antiseptic property of 
the (otherwise copious) bile in the young, chronic pulmonary tuber- 
culosis, and after severe cases of diphtheria or scarlatina, or in alco- 
holism and acute meningitis, an actual fatty degeneration is liable 
to occur, with enlargement of the organ. Dead foundlings are re- 
ported with fatty liver in forty-one per cent, of the cases. Sometimes 
it is found combined with interstitial inflammation (cirrhosis), par- 
ticularly in cases of syphilis, rhachitis, tuberculosis, or after measles 
or scarlet fever. All of these facts are here alluded to in order to 
show that the intellectual physician may accomplish a great deal by 
attending to an evil before it is developed. Nothing is easier and 
more luckless than to prescribe iodides, calomel, or purgatives for an 
established local disorder, and fold the hands at the sight of an impos- 
sibility; nothing more efficient and happy than to watch and treat 
in time rhachitis and measles and scarlatina and the whole army of 
primary ailments. Obsta principiis. Noiseless prevention counts more 
than the loud officiousness of the recipe fiend after the evil has been 
permitted to advance to maturity. 

Besides the cirrhotic induration of the liver complicated with 
fatty infiltration, there are instances of genuine cases of cirrhosis, 
mostly connected with, or depending on, cardiac disease (myocarditis 
mostly), parenchymatous inflammatory disease of the liver, alcohol- 
ism, syphilis, rhachitis, acute exanthemata (measles, scarlatina), and 
tuberculosis, also arsenic or phosphorus poisoning. Thus it is either 
circulatory or toxic. Of microbes, Charin found bacillus pyocyaneus, 
Weaver bacillus coli, Hektoen bacillus coli and pseudodiphtherise. 
Flexner found toxalbumins of different origins. According to all 
these observers, cirrhosis of the liver destroys the vital capacity of the 
organ, so that microbes are no longer annihilated by it. Adami found 
bacillus coli alive in the diseased liver, dead in the normal. The atro- 
phic form is rare and mostly due to syphilis; the hypertrophic, with 
more or less jaundice and only a mild degree of splenic enlargement, 
is more frequent. Still, both forms may develop in the course of the 



FATTY LIVER. CIRRHOSIS. CONGESTION 369 

same process, the atrophic being the last development of the hypertro- 
phic form. Pigmentary cirrhosis of the liver (and pancreas) is some- 
times a symptom of hsematochromatosis connected with (bronzed) 
diabetes. Cirrhosis of the liver is by no means so rare as it was be- 
lieved to be before attention was paid to it. It took a long time before 
a hundred cases were enumerated in literature. That has changed. 
Gilbert and Fournier (Sem. Med., 1895, p. 248) published six cases of 
from five to eleven years. There was jaundice in all, the spleens were 
large, in some cases larger than the liver, the last phalanges of fingers 
and toes were enlarged, the nails curved, the ends of femora, tibiae, and 
fibulas enlarged, many joints painful, and there was synovial effusion 
in the knees. All the children were undersized and puny. Ascites 
is not so frequent in the young as it is in the adult ; it is more often 
observed as the result of chronic peritonitis than of cirrhosis, and of 
portal obstruction of any kind. The energetic suppression of the 
alcohol habit (more frequently found in children and adolescents than 
many presume) and the treatment of syphilis (not always hereditary) 
may result in recovery. Ascites gets well sometimes after a single 
paracentesis. Mercury and iodides are very effective, not alone in 
syphilitic cases. In every sort of cases, and at every age, I have 
succeeded in relieving cirrhosis, and sometimes permanently, by alter- 
nating, by the week or fortnight, the administration of iodides (potas- 
sium or sodium, iodipin) and mercury (bichloride or the green iodide, 
and sometimes calomel). The bowels should be kept open with salines 
(sodium or magnesium sulphate), and diuresis improved. It is true 
that, as a rule, organized exudates will not melt and become absorbed 
when old, but recent cell proliferations submit to medicinal interfer- 
ence. Collateral circulation has been established for the purpose of 
draining the liver and re-establishing local circulation. The liver, 
spleen, and peritoneum were actively rubbed in order to cause an 
inflammation, successfully in a few cases. Forty years ago I injected 
tincture of iodine into the abdominal cavity of an alcoholic cirrhotic 
of fifty years after having been obliged to tap a dozen times at short 
intervals. The result was a formidable peritonitis and no more ascites 
for about four more years, when he died of senile general degenera- 
tion and a moderate attack of ascites. 

The therapeutics of congestion of the liver is that of its causes, — 
viz., the lungs and heart, phosphorus poisoning, infectious fevers, or 
very high temperatures. While nothing is more preposterous than the 
abuse of antipyretics in the presence of moderate temperatures, nothing 
is more reprehensible than to allow paralysis of blood-vessels and even 
disintegration of tissues to take place from excessive pyrexia. The 

24 



370 DISEASES OF THE DIGESTIVE ORGANS 

same is true of hepatic inflammation and suppuration. In our country 
the former, when general, is mostly traumatic, the latter the result 
of bacillus coli infection, pyaemia, umbilical phlebitis, dysentery, 
perityphlitis, and pleuritis, besides an occasional case produced by 
pylephlebitis, or the immigration of an ascaris, or a contusion. Many 
a case of abscess need not have occurred if the dysenteric rectum had 
been disinfected by frequent enemata, a perityphlitic or pleural abscess 
been incised in time, and the umbilical phlebitis of the newly-born 
prevented by keeping the cord aseptic. Multiple abscesses will always 
terminate fatally; a single abscess may get well by either aspiration 
or incision and drainage. Of the two I prefer the latter, though, 
indeed, I have seen a successful result from a single aspiration fol- 
lowed by antiseptic irrigation. The diagnosis of hepatic abscess from 
subdiaphragmatic abscess may become difficult. It is not very rare; 
in one hundred and seventy-six cases collected by Lanz twelve oc- 
curred in children. Intestinal disease very often precedes it. The 
skin is sensitive, the pain radiating, the liver and heart are not dis- 
lodged, the dulness is most marked over the sixth rib behind and the 
third and fourth ribs in front, the lung being normal above it. The 
puncture should be made during expiration (Fiirbringer). 

Acute yellow atrophy has been observed in infants of from one 
month to fourteen years. Greves (Liverp. Med. Surg. Journ., July, 
1884) collected seventeen cases ; I have seen but two, with pain, vom- 
iting, jaundice, nephritis, fever, and early brain symptoms. They all 
die, mostly within a week. 

The treatment of jaundice depends on its causes. The dangerous 
form met with in the septic newly-born might have been prevented, 
but cannot be cured. That which results from syphilitic stricture 
of the bile-ducts may recover, even after months, through a thorough 
mercurial treatment ; complete obliteration of the bile-ducts leaves no 
hope, except in those cases which can be proved to be inflammatory. 
In them persistent alternation of mercury and iodides may relieve, or 
restore health. With mercury alone, aided by but little potassium 
iodide in the rectum, a child of ten years with large and hard liver 
(probably fatty, previously) got well of icterus which lasted five months 
and was complicated with secondary nephritis. The mild form depend- 
ing on the sudden postnatal change in the hepatic circulation corrects 
itself ; that which follows a gastric and duodenal catarrh in the newly- 
born, the infant (rarely), or the child will get well with proper diet 
and medicines, which have to be adapted both to individuality and 
age. As a rule, the amount of food ought to be diminished, but little 
meat (chicken) permitted, and milk and farinaceous foods preferred. 



LIVER. ABSCESS. ATROPHY. PSEUDOPLASMS 371 

Alkaline waters (Seltzer, Vichy, Waukesha, Poland), sodium bicar- 
bonate or phosphate, bismuth, hydrochloric acid, resorcin, and calomel 
will be found appropriate in a great many cases; in others, copious 
cool enemata or tinctura rhei aquosa. Jaundice attributed to the in- 
fluence of foods, localities, miasms, and atmospheric influences has 
been observed to occur epidemically. J. M. Da Costa {Amer. Jour. 
Med. Sci., August, 1899) published a case of typhoid cholecystitis 
which occurred in a girl of eight years, with pain, vomiting, and jaun- 
dice. Ice, afterwards warmth, and the subcutaneous use of morphine 
relieved her. Such cases require, besides the treatment outlined above, 
rest in bed, warm bathing, and diaphoretics. H. Pletzer {Seventh 
Ann. Rep. Health Dep., Bremen) reports an extensive epidemic, not 
contagious, after revaccination. The glycerin lymph (humanized) 
which was employed was all obtained through different agents from 
Eastern Prussia. Jaundice from gall-stones, though it has been ob- 
served in the very young, even in the newly-born, is excessively rare. 
The rules for both dietetic and medicinal treatment o£ biliary calculi 
must be the same at all periods of life. Strictly nitrogenous food 
should be avoided or taken in small quantities only, and milk and fruit 
(oranges, grapes) and fresh vegetables permitted. Of all the medi- 
cinal agents known to me, sodium sulphate and salicylate, administered 
for months in succession, have answered best to guard against a repe- 
tition of the attacks. 

Baccelli's method of operation in echinococcns of the liver consists 
in aspirating thirty cubic centimetres (one ounce) of the liquid through 
a thin aseptic trocar and injecting twenty cubic centimetres of a one- 
per-mille solution of corrosive sublimate. The puncture is then cov- 
ered with gauze and adhesive plaster. In a few days the sac begins 
to diminish, and finally contracts. J. von Bokay published three suc- 
cessful cases {Arch. f. Kind., 1897, p. 310). The cases are rare, 
but may occur in everybody's practice. Cruveilhier saw one in an 
infant of twelve days. Finsen reported twenty-one cases between 
ten and fifteen years in a total number of two hundred and forty- 
five. The methods of operation have been puncture, puncture and 
injection of iodine preparations, puncture and drainage, simple in- 
cisions, the use of caustics followed later by incision, and two inci- 
sions, the second to be made after adhesion between the liver or sac 
and the peritoneum has been established. This method is the safest 
by far. 

Cancer (mostly scirrhous) of the liver is rare. A case was ob- 
served at birth by Noeggerath and one by me. Twenty-one cases have 
been collected in early life. It may begin as an adenoma, with rapid 



372 DISEASES OF THE DIGESTIVE ORGANS 

growth, tumor of the spleen, ascites, and hemorrhages. No treatment 
yet beyond that looking for euthanasia. 

H. Peritonitis. 

Whether acute, subacute, or chronic, it is a frequent occurrence 
at any age and quite common in the young. The several forms will 
interchange and combine or alternate with one another; the chronic 
variety may remain dormant through an indefinite period, and sud- 
denly break out with full force. All the forms of septic and infectious 
diseases give rise to it, from the sepsis of the newly-born to scarlatina, 
erysipelas, variola, dysentery, and typhoid fever (much more fre- 
quently without than with perforation). Trauma and perforation 
from any source, straining and contusion, indigestion, diarrhoea, and 
constipation (less frequently in the young than in the adult) will lead 
to it. Diarrhoea is a frequent cause of local peritonitis, the process 
penetrating the thickness of the intestine. Local disintegration of the 
serous membrane, possible with unexpected perforation during any 
period of later life, may be its result. The same is observed as the 
result of a healed typhoid ulceration. Inflammatory processes in the 
neighborhood, such as pleuritis, or simply local irritation from incipi- 
ent hernia or retained testicle, are among the frequent causes. Per- 
haps the most common origin is that from a previous attack which 
occurred at a period ever so distant. After all that has been said 
in these brief lines, it is easy to see to what extent preventive treat- 
ment may prove effective. The watching and mitigation of an infec- 
tious disease with a typical course, the speedy disinfection of the intes- 
tines in typhoid fever and dysentery, the prevention or cure of chronic 
constipation or diarrhoea, the proper attendance on appendicitis and 
pleuritis, the application of a truss and alleviation of the dangers of 
a strangulated testicle, are just so many safeguards against attacks of 
peritonitis. 

When an acute attack of peritonitis, either local or general, has 
made its appearance, absolute rest is required by the whole body as 
well as the affected organs. No unnecessary exertion, no motion of 
the body, no sitting up to evacuate either bladder or bowels, and no 
straining are permissible ; no food other than liquid ; that is, milk and 
such farinacea as contain least starch, — viz., ground barley or oatmeal, 
preferably the former. Meat requires more pepsin and hydrochloric 
acid than a stomach at a temperature of 104 or 106 F. is competent 
to furnish, and the system has no worse enemy than half-completed or 
unabsorbed peptones. Peristalsis must be stopped, for any disturb- 
ance of the consolidation of beginning adhesion is followed by the 



PERITONITIS 



373 



tearing of newly formed blood-vessels, the occurrence of hemorrhages, 
and the increase of danger. Opiates should be given by the mouth, 
rectum, or subcutaneously, or by combined methods, in doses suffi- 
ciently large not only to benumb pain or to procure occasional sleep, 
but to obtain a condition of constant drowsiness, even sopor, and an 
effect on the pulse. When there is much vomiting, food ought to be 
withheld for half a day or a day. There are cases in which even ice- 
pills furnish a new source of gastric irritation; still more frequent 
is the contraindication to carbonic acid gas, which, it is true, gives 
great relief in some cases, either in an alkaline water or in champagne. 
In the later stages of the disease, when the necessity of feeding becomes 
urgent, vomiting may often be avoided by giving, either subcuta- 
neously or on the tongue, undiluted, one or a few drops of Magendie's 
solution five minutes before the partaking of food. In the first days 
of acute peritonitis water is a greater necessity than food. When it 
cannot be introduced into the stomach, an ounce or two may be thrown 
into the rectum every hour or two hours without annoying it and 
without inducing peristalsis of the intestinal tract. A drop of tincture 
of opium may be added to it. 

Ice-bags, or, if they be too heavy, the ice-water coil, or iced cloths 
are applied to the abdomen ; the former mainly while the inflammation 
is still local. When they are objected to, water of the usual tempera- 
ture may be employed first and the latter reduced gradually. Cold 
must not be employed too long in very young or anaemic children ; 
in these, indeed, warm applications are tolerated best. As long as an 
acute peritonitis is still local (pericystitis, perihepatitis), leeches may 
be expected to do good. No purgatives must be given. In children 
peritonitis caused by constipation is exceedingly rare, and the recom- 
mendations of magnesium sulphate given by gynsecologists in puer- 
peral and other forms of peritonitis for the alleged reason that it 
prevents adhesions, though they may be considered justifiable in the 
adult, do not hold good for the infant or child. If it be desirable 
to relieve the intestinal tract to some extent, the incipient state of per- 
itonitis may permit of a tepid enema gently administered, with or 
without the addition of a teaspoonful or half a tablespoonful of oil of 
turpentine added to half a pint or a pint of warm water, or a few ounces 
of olive oil may be injected. Rest to the intestinal tract is such an abso- 
lute indication that the locking up of the bowels for a week or ten 
days frequently become a necessity. The tympanites of peritonitis is 
not the result of constipation, but depends on the paralytic condition 
of the muscular layers of the gut, brought about mostly by oedematous 
effusion into its tissues. But when it becomes very annoying or 



374 DISEASES OF THE DIGESTIVE ORGANS 

dangerous through pressure upon the diaphragm, relief may some- 
times be obtained by introducing one or more tubes of India-rubber 
into the rectum. External applications must not be made because 
of the danger attending renewed peristalsis. The question whether 
puncture of the intestine is advisable, with a view of allowing gas 
to escape, cannot be answered for every case. Experience has shown 
that such punctures accomplished this purpose, but also that over- 
extension of the intestinal wall destroyed its elasticity and prevented 
the puncture from closing immediately. I have seen liquid faeces in 
the abdominal cavity which had escaped through the fine apertures 
made by the needle of the aspirator. 

When the case proves to be one of suppurative peritonitis, the 
accumulation of pus may be circumscribed (a local abscess) or the 
whole abdominal cavity may be affected. In such cases there have oc- 
curred occasional perforations into and discharges through the intes- 
tine, ureters, bladder, or umbilicus, but it is not windfalls or godsends 
we have to calculate upon or look for. The choice is between an 
absolutely bad prognosis and the incision of the abscess, or laparotomy 
with proper after-treatment (p. 355). As to its performance, I refer 
to the recent books on surgery. If I have anything to suggest, it is 
that the incisions should not be too small. The latter operation has 
also been recommended as a curative agent in tubercular peritonitis. 
Tubercular peritonitis is mostly a disease of long duration. Its first 
symptom is quite often ascites, the effusion having a high specific 
gravity and containing much albumin. There may be swelled inguinal 
glands, which are of little account; hard masses in the abdominal 
cavity mean exudate, adhering intestines, and sometimes tubercular 
lymph-bodies of the mesentery. Pain, swelled lymph-bodies about the 
neck, pulmonary and pleural symptoms, and fever are bad complica- 
tions. Many uncomplicated cases get well without special treatment ; 
some with iodides or with general antitubercular treatment (p. 163). 
Caille (Festschrift) asserts that medication is of no use, and that an 
operation should be made early. This much is certain, that it should 
not be delayed when there is a fever which persists, when medication 
is unavailing, when the ascites does not diminish, and when emaciation 
increases. Punctures and inflation of sterile air have been recom- 
mended by J. Duran ; but laparotomy, with emptying of the abdom- 
inal cavity and immediate closure of the wound, is frequently made, 
and many successes are claimed. The alleged causes of the healing 
influence of laparotomy are many : the contact with chemicals, such as 
iodoform and other antiseptics, with air, with light, with bacteria 
entering from outside, or the removal of the exudate itself. It is very 



TUBERCULAR PERITONITIS. ASCITES 375 

probable, however, that the consecutive hyperemia has the most benefi- 
cent influence. 

Chronic peritonitis, whether the outcome of an acute attack or an 
independent affection, has its own indications. The majority of cases 
are either traumatic or the results of previous diarrhoea, typhoid fever, 
or tuberculosis. Exudates may be very bulky, and still the case may 
get well. Rest in bed, warm bathing, and warm poultices offer great 
relief. Baths containing iodine, such as St. Catherine, Kreuznach, 
and the internal administration of potassium or sodium iodide (of 
iron only when there has been no elevation of temperature for some 
time) will contribute to the absorption of part of the exudation, par- 
ticularly when the latter is very massive. An occasional vesicatory 
will be found opportune. Iodoform may be used as an ointment, or be 
applied in collodion (1 to 8 or 12), twice daily, for a long time. Tinc- 
ture of iodine is less efficient and more irritating. Ascites may require 
paracentesis, but I have seen many a case improved by iodides only, in 
connection with other diuretics. Sparteine sulphate (scoparius)is one 
of the best, in daily doses of, altogether, from one to four grains (0.06 
to 0.25) . It may be combined with the iodide, but not in the same mix- 
ture. When the solid exudation is obstinate, the blue ointment may be 
used in addition to the iodide ; it may be rubbed into the inner aspect 
of the thighs or forearms, particularly the former, twice daily; not 
however, into the abdominal wall. Nothing is easier than to transform 
a mild chronic form into an acute peritonitis by friction and similar 
traumatism, and nothing more certain than that the modern " mas- 
sage" craze has multiplied the cases and that every important massage 
case should be treated by a physician or a conscientious expert. On 
the other hand, there is no better means of alleviation and prevention 
than rest secured to the abdominal organs by the permanent wearing 
by the patients, or by those who ever suffered from peritonitis, of a 
bandage easy enough not to annoy, but sufficiently snug to hold in 
position the jumble of formerly diseased and still vulnerable adhering 
intestinal convolutions. 

Ascites has been mentioned as the result of the local obstruction of 
the portal circulation (p. 369), of cirrhosis of the liver, and of acute 
and chronic peritonitis ; the treatment depends on the cause. Cardiac 
and renal ascites require potassium bitartrate and other salines, now 
and then drastics, and those drugs which increase blood-pressure 
and diuresis ; digitalis more frequently in children than in old people ; 
sparteine sulphate, caffeine, abstinence from alcohol and, so far as pos- 
sible, from water ; tapping when indicated by dyspnoea. Ascites may 
depend on or be connected with congenital or acquired tumors of the 



376 DISEASES OF THE DIGESTIVE ORGANS 

peritoneum. Cystic tumors may be chylous, lymphatic, sanguineous, 
dermoids, echinococcus, or cysticercus. Lymphangioma may be simple 
dilatations, through obliteration of the thoracic duct or other lymph- 
vessels, or neoplastic. Possibly now and then a mesenteric lymph-body 
may undergo cystic degeneration. The treatment is that of ascites 
(paracentesis), and causal if possible; that means extirpation. 

Ascites chylosus is rare even in the adult ; but the young are not 
exempt. Congenital weakness and fragility of the lymph-vessels, with 
or without their dilatation (cases originating from lymphangioma are 
known to have occurred in the adult), and the frequency of chronic 
peritonitis suggest the explanation of their occurrence. Of filariasis 
in children, I know of no case. Czerny had the case of a girl of ten 
years, in which the chylous ascites was due to the pressure on the ducts 
by ovarian and lymph-gland sarcoma, Wilhelms that of a child with a 
tumor in front of the vertebral column, in which the disease developed 
two months after recovery from whooping-cough. 



VIII 

Diseases of the Genito- Urinary Organs 

I. The Kidneys. 
The preventive treatment of the kidneys ought to begin with the 
first hours of the newly-born. After the second day, and frequently 
through a period of some two or three weeks, the urine, usually 
thin and limpid in the infant, is liable to eliminate a large amount 
of uric acid and urates. They are deposited in the pyramids and 
papillae of the kidneys, also in the straight uriniferous tubes, even in 
the epithelia, as orange-colored crystals and an amorphous powder, 
and are sometimes so copious as to accumulate in the pelvis of the 
organ and also in the bladder. Not infrequently these deposits are 
combined with some organic structure, which is dissolved by acetic 
acid, or with hsematoidin crystals resulting from small extravasations. 
A frequent constituent of the deposits is bilirubin, which is soluble 
with difficulty only in alkaline fluids (blood). Orth and Neumann 
succeeded in obtaining crystallized bilirubin from the dead bodies of 
icteric infants. Quite often the dress of the baby is discolored by 
them. The presence of this uric acid infarction is due to the sud- 
den change in the circulation of the blood; it causes an unprece- 
dented elimination of nitrogenous material which cannot be kept 
in solution and easily removed, partly because the newly-born is not 
supplied with a sufficient amount of water. Its speedy expulsion is 
of great importance, for it acts as a local irritant, and may give rise 
to a slight or copious renal hemorrhage, to albuminuria (which is 
a frequent occurrence because of the defective construction of the 
epithelium of the glomeruli), and even to nephritis. Besides, its 
presence in both the kidneys and the bladder is a ready cause of 
the formation of renal calculi ; indeed, the vast majority of renal 
calculi and the centres of vesical calculi consist of uric acid with 
some amorphous organic material. The consideration of these facts 
conveys at once the conviction of the necessity of supplying the 
newly-born with ample quantities of water. Much suffering and ill- 
ness can thus be prevented.* 

* See my paper on Nephritis in the Newly-Born, N. Y. Med. Journal, 
January 18, 1896. 

377 



tf8 DISEASES OF THE GENITO-URINARY ORGANS 

The malformations of the kidneys and their (mostly congenital) 
malignant pseudoplasms furnish but few indications for treatment. 
Abnormal shape and unicity of the kidney (sometimes amounting 
to horseshoe kidney), cystic degeneration of obstructed uriniferous 
tubes,* tubular adenoma, carcinoma, and sarcoma, including rhabdo- 
myosarcoma, which is an early degeneration of the Wolffian body 
and contains cartilage and muscle, are, unfortunately, not uncommon. 
I collected nearly four dozen sarcomata in the fcetus and infant in 
my paper on the subject presented to the Eighth International Con- 
gress, 1884. From that time dates the differentiation between sar- 
coma and carcinoma of the kidneys, and the cases of the former have 
become very numerous. Pseudoplasms of the renal capsule are either 
lipomata or sarcomata. No treatment can be advised but that of 
removal before the tumor becomes too large and metastases have 
taken place ; if they are observed at an early period, the case is proba- 
bly one of carcinoma, not of sarcoma. (See H. Rehn in Festschrift, 
and Jacobi in Trans. Tenth Inter. Med. Congress, 1884.) If nephrec- 
tomy be no longer possible, Coley's subcutaneous injections of ery- 
sipelas antitoxin may be tried. Fortunately, the diagnosis can be 
made with satisfactory certainty, and besides, as a rule, but one 
kidney is affected. Metastatic deposits in the other kidney or in 
other organs take place, if at all, at a late period of the development 
of the pseudoplasm. In cases of sarcoma, the removal of the tumor 
as soon as the diagnosis (slow growth mostly, tumor painless, sense 
of semi-fluctuation, colon in front of the tumor, usually no hem- 
orrhage, which is more characteristic of carcinoma, rarely any metas- 
tasis) is made yields sufficiently favorable results. Concetti (Rif. 
ined., 1898) has the following figures: forty per cent, died after the 
operation ; forty-five per cent, died of relapses ; seven per cent, were 
well two years after the operation; in eight per cent, the results 
were unknown. Schmieder {Deutsche Zeitsch. f. Chir., vol. lxii.) 
concludes that nephrectomy, mostly performed for malignant tumors, 
has more favorable results in the young than in advanced years. Of 
three hundred and twenty-nine extirpations one hundred and seven- 
teen were made on patients of less than fifteen years ; most of these 
were quite young. 

Primary tuberculosis is more frequent in the kidneys than in any 
other part of the urinary tract. It is more frequently descending 

* M. A. Couvelaire (Comptes-rend. de la Soc. d'Obst, Gyn., et Psed., vol. 
iv. 1902) publishes a case of cystic degeneration of the kidneys, liver, and 
pancreas. 



KIDNEYS. TUBERCULOSIS. PSEUDOPLASMS. PTOSIS 



379 



than ascending, and at first but one kidney is affected, afterwards 
both; it begins in the cortex, affects the base of the pyramids, and 
may terminate in abscess. There are enuresis and local continuous 
or paroxysmal pain; blood, pus, connective and elastic fibres are 
found in the urine, sometimes uric acid sediments or calculi. The 
diagnosis is difficult until bacilli are discovered. They are scarcely 
found except by centrifuging. Repeated examinations may be re- 
quired. For the most careful and comprehensive presentation of 
the whole subject I advise to compare Fred. E. Sondern in Fest- 
schrift. Of fifty-four cases reported by S. M. Hamill (Intemat. 
Med. Journ., January, 1896) seventeen were operated upon; four 
nephrotomies cured two, improved one ; one died. Nephrectomy 
was performed on nine; five were cured, one improved, three died. 
Nephrotomy and subsequently nephrectomy were performed on four ; 
one died. Of Palet's one hundred and thirty-six nephrectomies only 
twenty-nine proved successful beyond a year's time. General anti- 
tubercular treatment with guaiacol, etc., should not be omitted. It is 
here that ammonium sulpho-ichthyolate is recommended. Of a solu- 
tion in equal parts of water from ten to seventy drops (the latter to 
adults) were given three times a day. 

Echinococcus and hydronephrosis furnish the usual indications. 
More than one-half of the latter are congenital, and therefore unfavor- 
able. The secondary variety is caused by congenital hypertrophy of 
the bladder, pseudoplasms in the bladder or pelvis, calculi or abnormal 
valves obstructing a ureter, tuberculosis or shrinking, with partial ob- 
literation, of the ureter, disease of the prostate gland and urethra and 
its neighborhood. Thus the prognosis of the causal treatment is very 
doubtful in most cases, and a direct surgical treatment — aspiration, 
drainage, and irritant injections — is demanded. A cystic tumor weigh- 
ing three pounds was removed from a child of seven months by 
J. Campbell (Br. Med. Jonrn., May 15, 1897). It was located in 
front of the left kidney, and contained three hundred grammes of a 
clear yellow fluid and a solid mass in which a cartilage and a piece of 
bone were embedded. 

Most cases of Hooting kidneys in infants and children are con- 
genital; in a few older children, of ten and twelve years, symptoms 
attributable to that anomaly originated in a fall or jump from a 
height. Fortunately, it is a rare occurrence in the first decade; still, 
I have met with at least a dozen such in the course of more than 
forty years. Among the dispositions I mention the large size of 
the adrenals and the congenital flatness of the paravertebral cavity, 
a flabby capsule and great length of the renal vessels, also a long, 



380 DISEASES OF THE GENITOURINARY ORGANS 

narrow chest and generally weak muscles. Among the causes are 
rapid loss of fat, increased intra-abdominal pressure (cough, vomiting, 
constipation) , trauma, and hydronephrosis. The right kidney is mostly 
affected, it being normally lower than the left. The left curvature 
of the colon is more closely attached to the ribs and less to the 
kidney. I never could advise anything better than a snug and well- 
fitting abdominal bandage. I have not seen a case in which I felt 
justified in advising an operation (nephropexy). 

Among the symptoms connected with urinary disease there are 
two of such importance as to render a special consideration advisable, 
— viz., hematuria and hemoglobinuria. The former is always the 
result of a rupture of blood-vessels, which may be occasioned by 
many causes. Haemophilia furnishes a strong predisposition ; so does 
heredity. Guthrie {Lancet, May 3, 1902) reports the occurrence 
during a number of years of hematuria in twelve members of a 
family. Calculus in a kidney or the bladder, nephritis and cystitis, 
neoplasms (mainly carcinoma, not often sarcoma), thrombosis of the 
renal vein, or infectious diseases, such as purpura, cerebro-spinal 
meningitis, and scurvy or malaria, are among the principal causes of 
hematuria. So is irritant medication with cantharides or turpentine. 
There are, besides, cases isolated, or recurrent, for which no tangible 
cause can be held responsible, not even sudden exposure of the sur- 
face or excessive amounts of uric acid or oxalates in the urine. The 
angioneurotic form I have not seen in a child. The indications fur- 
nished in renal hemorrhage by the presence of infectious diseases 
and thrombosis are clear, but the efficacy of the means considered 
appropriate is very doubtful. Stone in the kidneys requires flushing 
the organ with alkali according to the methods to be discussed below. 
The action of ergot or of hydrastis, either as a fluid or a solid extract, 
may be tried. If the stomach be rebellious the remedy may be ad- 
ministered in the rectum or subcutaneously. Heart stimulants are 
often indicated, but digitalis should not be selected, because of its pos- 
sible local effect on the kidneys. Strophanthus or sparteine sulphate 
is preferable. Astringents such as are eliminated through the kid- 
neys, — lead, gallic acid (eight to thirty grains = 0.5 to 2.0 daily), — 
with. or without appropriate small doses of morphine, will render good 
service if given in more than the doses of the books. The temporary 
application of ice over the bleeding kidney is superior to any other 
remedy, even in the very young ; it may be resorted to before or after 
the powerful derivant effect of a hot mustard-bath has been tried. 
Drop doses of adrenalin (Parke, Davis & Co.) may be given several 
times a day. Ten cubic centimetres (two and a half teaspoonfuls) of 



HEMATURIA. HEMOGLOBINURIA. NEPHRITIS 381 

a two-per-cent. solution of gelatin thoroughly sterilized may be used 
subcutaneously and repeated, also teaspoon doses of a ten-per-cent. 
solution internally, from time to time. Harrison (Br. Med. Journ., 
1896, No. 35) relieved hematuria by long incisions into the kidney. 
Israel's cases of the same kind have been in part successful. Even 
simple exposure of the kidney, and manipulation, had a similar effect 
in a number of cases. 

Hemoglobinuria, resulting from dissolution of blood-cells, is the 
occasional effect of extensive burns, overexertion, sudden exposure, 
intense cold, poisoning with potassic chlorate, phosphorus, and in 
scarlatina, syphilis, malaria, and sometimes paroxysmally without a 
tangible cause. In the urine, besides haemoglobin, blood and casts 
may be found; in autopsies mostly blood in the capsule and in the 
canaliculi, besides detritus. 

Nephritis, in the acute, subacute, and chronic forms, is a very 
frequent disease in infancy and childhood. There is an occasional 
hereditary tendency. Even in the newly-born it is not infrequent 
(N. Y. Med. Journ., January 18, 1896). In these it is either conges- 
tive (from feeble circulation, congenital heart disease, asphyxia, or 
exposure to low temperatures), or obstructive (from the physiological 
rapid decomposition of the blood in the newly-born, the formation 
of haematoidin = bilirubin, from jaundice, from the production of 
methaemoglobin by potassium chlorate or by excessive heat, or from 
the presence of blood in the uriniferous tubes), or irritative (by uric 
acid or by haematoidin infarctions, by the presence of purpuric or 
other hemorrhages, or of microbes and toxins furnished by enteritis 
or by an infectious disease). As nephritis is not always primary, but 
quite often a secondary affection, it is liable to be overlooked until 
it is too late. When this excessive frequency is generally recognized, 
fatal results will become less common and prevention will be appre- 
ciated at its full value. The enumeration of the causes of nephritis 
will always be incomplete, but the list of those conditions and diseases 
leading to it comprehends the principal ailments of infancy and child- 
hood. First of all, there are the acute infectious diseases : scarlatina, 
diphtheria, measles, rubella, varicella, vaccinia even, malaria, typhoid 
and cerebro-spinal fevers, amygdalitis ("tonsillitis"), parotitis, and 
pyaemia. No bacilli are required to cause a toxic nephritis ; their 
toxins do it as well. Malaria is a frequent cause of nephritis in some 
countries or regions (Busey, Am. Med. Asso., 1880) : the South of the 
United States, the shores of the Baltic Sea and of the lower Danube. 
There are constitutional disorders, such as syphilis, purpura, and dia- 
betes, also enteritis, extensive eczema, or impetigo, changes in the 



382 DISEASES OF THE GENITO-URINARY ORGANS 

superficial circulation resulting from sudden exposure, sometimes also 
from the persistent influence of a low temperature. The latter is 
not so ominous as the former. A fall into the water or exposure to a 
rain-storm may cause an acute nephritis (interstitial or hemorrhagic) 
which may prove fatal in a few days. The slow influence of cold 
temperatures is better borne, almost as well as compulsory overwork 
of a kidney (for instance, after the other has been removed). Stasis 
and thrombosis, depending on pulmonary and cardiac diseases and 
diarrhoea, have the same result. Irritation of the kidneys by medici- 
nal agents also leads to nephritis; for instance, potassium chlorate, 
mineral acids, salicylic, carbolic, and pyrogallic acids, turpentine, 
naphtol, styrax, petroleum, tar,* large doses of lead, phosphorus, 
arsenic, mercury, and manganese, — part of which are used for internal, 
part for external medication; finally, irritation of the organ by the 
uric acid infarction of the newly-born, or by renal calculi, which are 
by no means rare in the very young, gives rise to inflammation. Most 
of these injurious substances exhibit their detrimental effect the more 
the younger the infants ; in them a single external application of a 
solution of carbolic acid has sufficed to produce nephritis. The large 
number of causes of nephritis, as enumerated above, if heeded, teaches 
at least two lessons : first, that supine expectancy in the treatment 
of digestive and infectious diseases is very liable to become criminal ; 
and, secondly, that the effect of every irritating remedy, both internal 
and external, must be carefully watched. 

Nephritis should never be overlooked. Almost no diagnosis of 
any disease is complete without an examination of the urine. An 
elastic catheter is more easily introduced into the bladder of a male 
infant or child than into that of an adult, and in the other sex it 
is almost equally easy. If the catheter be not used, absorbent cotton 
will furnish a sufficient quantity of urine, or a rubber bag over the 
penis will secure it. The examination for albumin should never be 
omitted in a doubtful case or in any of the infectious diseases. Albu- 
minuria should never be considered an indifferent matter, not even 
the " physiological" secretion of a faint trace of albumin in the newly- 
born. It certainly means an inefficiency of the glomerular epithelium. 
In nephritis of whatsoever origin it is one of the symptoms, no matter 

* Balsam of Peru has also been charged with occasioning nephritis. Brau- 
tigam and Nowack, after having made daily examinations of the urines of 
twenty-two patients, though administering internally fifty-two and eight-tenths 
grammes in eleven days and in another case eighty grammes in twenty-four 
days, found that it has no such detrimental effect, provided it be free of 
ethereal oils (Centralb. f. klin. Med., No. 7, 1890). 



ACUTE NEPHRITIS 383 

how trifling its amount in the chronic form, in which it may be absent 
for days or weeks. Toxins contained in the intestines will cause it; 
in many cases there is indicanuria at the same time. If the venous 
circulation is much obstructed during digestion, particularly when the 
efferent vessels of the renal territory are without valves, albuminuria 
may result. Cyclic albuminuria was first described by Pavy, 1885. 
It was given its name on account of its absence early in the morning 
(and late in the evening) ; as soon as the recumbent position is given 
up and the muscles become active, it reappears. As it points to some 
instability of glomerular circulation and to epithelial incompetency, 
it should not be made light of, for it may lead to nephritis. I think 
I have seen a good effect from gallic acid, which may be given a long 
time in daily doses of from eight to thirty grains (0.5 to 2.0). 

When acute nephritis has been fully established, the first indica- 
tion consists in the procuring of relief for the congestion of the 
kidneys. The child must be in bed, the skin warm. A hot-air bath, of 
a duration of from ten minutes to one hour, of the whole body with the 
exception of the face, will cause copious diaphoresis ; a warm bath, 
with or without mustard, will fill the cutaneous blood-vessels and 
relieve the internal circulation; dry cups and hot poultices applied 
to the renal region will have a similar effect. The mucous membrane 
of the intestinal tract should be made to share in the action of 
the skin; therefore, magnesium sulphate should be administered 
in doses sufficient to produce three or four daily evacuations, or 
calomel in small doses frequently repeated. The arterial tension 
should be reduced by nitrites, particularly when there are cerebral 
symptoms ; besides aconite in frequent one-quarter-drop doses, small 
doses of opium frequently given, or chloral hydrate may be tried 
for the same purpose. Digitalis should be avoided in acute cases, 
but when exhaustion is threatening, strophanthus or sparteine sul- 
phate may be administered with the nitroglycerin. Potassium iodide 
acts favorably in the same direction ; sodium sulpho-ichthyolate has 
been recommended for the same purpose by Senator, who gives to an 
adult pills containing from one decigramme (one and a half grains) to 
one gramme (fifteen grains) daily. 

The greatest care must be bestowed on the diet of the patient. 
Whatever is irritating must be avoided ; for instance, alcohol, spice, 
or iron. The food should be exclusively liquid, warm or hot, and 
compatible with the vulnerable condition of the kidneys. As the 
first products of the metamorphosis of albuminates are eliminated 
through these organs, and some of its products, such as phenol, 
creatin, and extractive materials in general, may become positively 



384 DISEASES OF THE GENITO-URINARY ORGANS 

poisonous, it follows that strongly nitrogenous foods — the opposite 
opinion of Oertel and Loewenmeyer and their followers notwith- 
standing — must be prohibited. No eggs should be given and, as a 
rule, no meat; now and then an exception may be made in favor 
of veal, spring lamb, chicken, fish, or oysters; but, as a rule, the 
diet in acute nephritis must be confined to milk and farinacea. Barley, 
wheat (stale bread), hominy, rice, and potatoes are permissible, also 
green vegetables and fruit. The beverage consists of water or an 
alkaline mineral water. Lemonade is permissible unless it interfere 
with the digestion of milk. Neither in the acute, nor subacute, nor 
chronic form of nephritis must muscular exertion be allowed, for 
this increases the metamorphosis of the albuminates. Moderate exer- 
cise, however, is not contraindicated in the chronic form ; in the latter 
the elimination of albumin is not increased by exercise. 

The surrounding air is to be fairly warm when the patient is in 
bed, quite warm when he is about. The function of the skin must 
not be suppressed; a moderate amount of perspiration is beneficial. 
Thus it is that there is constant indication for warm bathing and a 
warm climate, for both diminish the labor of the kidneys (as also 
of the lungs). As moist air interferes with the action of the skin, a 
dry climate is preferable. Hot bathing must be avoided except in 
the very beginning and in the occasional emergencies of uraemia. 

Subacute nephritis, with its limpid and sometimes copious urine, 
changeable percentage of albumin, incidental cedema and gradual 
diminution of strength, occasional presence of arterial contraction 
and of cerebral symptoms, is often overlooked. It is a frequent 
sequela of scarlatina and diphtheria. Hot-air and hot-water baths, 
and iron, that is deposited in the epithelium of the uriniferous tubes 
(which is thereby subjected to premature elimination), should be 
avoided. Digitalis is contraindicated during high arterial tension ; 
indeed, there are but few cases which permit its administration. 
Small doses of opium benefit the circulation in most cases of uraemia 
complicated with high arterial pressure; so do the nitrites (sodium 
nitrite from two to six grains (0.1 to 0.4) daily, nitroglycerin one- 
two-hundredth grain, more or less, several times a day, or the spirit 
of nitrous ether), chloral hydrate, and sparteine sulphate. Mercury 
in small doses (corrosive sublimate), from one-fifteenth to one-tenth 
grain (0.004 to 0.006), largely diluted (1 to 8000 or 10,000 at least), 
may be given daily, week after week, and may be combined, in 
afebrile cases only, with small doses of iron. The alleged irritation 
of the kidneys by mercury need not be feared in these doses and 
dilutions. The air should be warm, a dry, warm climate selected, 



SUBACUTE AND CHRONIC NEPHRITIS 385 

and a warm bath given every day, with gentle friction. Large quan- 
tities of water, both pure and alkaline, should be shunned, for the 
functional activity of the kidney must be diminished so far as com- 
patible with a normal circulation and moderate metabolism. This 
rule is particularly stringent during the presence of local or general 
dropsy. Here the amount of liquid consumed ought not to be greater 
than the quantity of urine discharged. Mild diaphoretics and purga- 
tives will also relieve the labor of the kidneys. When the amount 
of uric acid in the urine is persistently large (lithaemic disposition), 
sodium salicylate may be administered daily to the total (daily) 
amount of from ten to fifteen grains (0.6 to 1.0), or sodium bicar- 
bonate in twice the doses. 

Chronic nephritis is of frequent occurrence. The presence of occa- 
sional headaches, or of vomiting, or a slow convalescence from any 
ailment is suspicious, and calls for the examination of the urine. As 
albuminuria is not always present, and the amount of albumin very 
changeable, that examination must be repeated at short intervals and 
with the best methods ; indeed, the use of the centrifuge reveals many 
a case of alleged trifling albuminuria, even of " transient" albuminuria, 
to be nephritis. That albuminuria should be differentiated from pep- 
tonuria (in the suppurations of empyema, bones, abdominal tumors, 
intestinal ulcerations, and in meningitis, sometimes in scurvy, rarely 
in syphilis, in phosphorus poisoning, and in acute rheumatism, also in 
leucocytosis of different origins) is self-understood; also that the 
albumin of pyelitis or pyelonephritis should not be mistaken for that 
of nephritis. The absence of dropsy or oedema proves nothing at 
all, particularly in the very young infant, in whom chronic nephritis 
without dropsy is a frequent occurrence after pleurisy, pneumonia, 
erysipelas, or in syphilis. Indeed, the most dangerous cases and 
complicated with uraemia are those in which no dropsical symptoms 
are apparent. Many a case of chronic nephritis could be prevented 
by the discovery of the acute or subacute stage preceding it, and 
by heeding its many causes. I have seen a number of cases compli- 
cating or rather depending on purpura, in which evidently the pres- 
ence of small hemorrhages in the renal tissue gave rise to the initial 
irritation. In these cases the constant use of phosphorus (one-one- 
hundred-and-fiftieth grain twice or three times daily) during two or 
three months in succession added greatly to the final recovery. 

Now and then a case of chronic nephritis will recover. The ma- 
jority of those I have seen getting well took corrosive sublimate. 
The " poisonous" effect of the drug was not apparent in such cases, 
nor in any case where it was watched. Children of five years may 

25 



386 DISEASES OF THE GENITO-URINARY ORGANS 

safely take one-fiftieth or one-sixtieth of a grain (o.ooi) in a table- 
spoonful of water three or four times daily for many weeks in suc- 
cession. When its intermission is deemed advisable, or together with 
the mercury, potassium iodide may be given in doses of six or 
ten grains (0.4 or 0.6) daily. At the same time iron may be admin- 
istered, the chloride (or one of the milder preparations), from ten 
to twenty drops of the tincture daily. A gentle stimulation of the 
kidneys by preparations of juniper or potassium bitartrate or citrate 
is advisable. Strong irritation of the kidneys must be avoided ; digi- 
talis is apt to do harm, except in complications with valvular lesions 
of the heart. To increase diuresis through strengthening the action 
of the heart, sparteine or caffeine renders better services ; the latter, 
however, should be carefully avoided when there are any cerebral 
symptoms. Among the best diuretics, through relieving the heart 
while diminishing arterial tension, is nitroglycerin or other nitrites, 
the mildest of which is sweet spirit of nitre. Small doses of opium 
are often useful. In cases of obstinate vomiting it is often the only 
reliable remedy. Diuretin appears to act more on the renal epithelia, 
and may be given daily, in doses of from five to thirty grains (0.3 to 
2.0), according to age. 

The prognosis of chronic nephritis (and of many cases of the acute 
form) being bad or doubtful, the operative procedures advised by 
Harrison, Israel, and Edebohls deserve attention. Harrison divides 
the capsule in acute cases for the relief of symptoms and the preven- 
tion of chronicity ; Israel in chronic nephritis for hematuria and 
renal colic ; Edebohls removes the fat from the dissected capsule for 
the purpose of starting a collateral circulation. 

The regulation of diet and hygiene is vital. No exposure to cold, 
no sudden changes of temperature; a warm and uniform climate. 
The chances of recovery diminish with the impossibility of obeying 
this rule. Sojourn in a hospital or refuge for the poor, as a make- 
shift. The proteids must be restricted, with the exception of milk. 
But it should not be forgotten that iron is almost absent from milk. 
That is why iron has always been recommended. Fruit and cereals 
contain it and should take the place of meat. Unfortunately (Van 
Noorden), the white meat contains almost as much extractive sub- 
stance as the dark. Avoid alcohol. 

Chronic nephritis may call for immediate and strong measures 
during some of its worst sequelae. Uraemia (rarely preceded by 
aphasia, occasioned by the accumulation of urea in the blood, the 
presence of cerebral oedema and of arterial contraction and heightened 
blood-pressure, and by reflex irritation of the motory centres) results 



CHRONIC NEPHRITIS. CALCULI 387 

in vomiting, diarrhoea, coma, and convulsions. Strong purgatives 
may be required at once (calomel, from five to ten grains; elaterium, 
one-twentieth grain; or croton oil, from one-twentieth to one-tenth 
grain every hour, to be followed by magnesium sulphate), or strong 
diaphoretics (hot-air bath, hot- water bath, hot-water pack, pilocarpine, 
subcutaneously, in doses of from a fifteenth to an eighth of a grain), 
and occasionally, when the symptoms of cerebral hypersemia predomi- 
nate, a few leeches to the septum narium (the preferable place) or 
the mastoid processes will save a case from imminent destruction. In 
older children a venesection may sometimes be required. If it is to 
be helpful it should not be deferred. When, however, much fluid is 
eliminated from the body through all these procedures, a new supply 
must be introduced either by the stomach or by the rectum. Injec- 
tions into the subcutaneous tissue, or into a vein, of large quantities 
of sterile salt water may be life-saving. Other sequelae or complica- 
tions have each their own indications; oedema of the glottis cannot 
wait for the effect of the above medication, and demands either scar- 
ification, or tracheotomy, or intubation. Hydropericardium and hydro- 
thorax require paracentesis when the symptoms are urgent. Ascites 
demands paracentesis to relieve dyspnoea and to facilitate the function 
of the abdominal viscera and of the circulatory organs. Quite often 
diuretics will begin their effect only after the pressure on the kidneys 
has been removed. 

Hypertrophy of the left (and right) heart is in adults some- 
times coordinate with chronic nephritis, in children it is almost 
exclusively secondary to it, " compensatory through the influence of 
the nervous system, also arterial change, irritated, it may be, by the 
later acquired toxic state of the blood due to defective renal function, 
but in part also to the primary cause which produced the primary 
renal disease, be it lead, gout, syphilis, alcohol, and the like" (Tyson 
in Festschrift). 

The frequency of renal calculi has been alluded to before. Indeed, 
they are quite common, have been observed to occur in the foetus, 
and give rise to many attacks of screaming, with dysuria, local 
pain, retraction of the testicles, to the occasional presence of pus, 
blood, and gravel in the urine, and to vomiting and convulsions. 
Most of them consist of uric acid, very few of oxalates, of cystin 
(several cases in a family), or of ammonium and magnesium 
phosphate, and derive their positive indications for treatment from 
their chemical composition. Unfortunately, however, the composition 
is mostly not uniform. Of forty-four cases of L. Spiegel (BerL 
kl. Woch., No. 27, 1900), two consisted of phosphates, one of uric 



388 DISEASES OF THE GENITO-URINARY ORGANS 

acid, one of xanthin, two of cystin, and the rest were of mixed consist- 
ency. Oxalates are frequent causes of stones in the kidneys of adults, 
rare in childhood. They are best dissolved by salts of magnesium, 
with a diet consisting of fish, fat, bread, rice, apples, and plenty of 
(soft) water. Calcareous deposits (carbonates or phosphates), 
which are found in the newly-born at the lower end of the straight 
canaliculi, near the papillae, and also in epithelia, being whitish, have 
been mistaken for interstitial infiltrations. Calculi, however, are not 
exclusively anorganic. The first uric acid infarctions are covered with 
organic material, and the calculus is gradually formed of the mixture 
of both. Small hemorrhages also contribute to it. Indeed, hemor- 
rhages may be both the results and the causes of calculi. Meckel 
spoke of a stone-forming catarrh in the kidneys, as we now know 
that a catarrh of the gall-bladder occasions the formation of gall- 
stones. Particularly in those cases which occur in gouty families 
the diet must be limited to a very small quantity of nitrogenous food. 
Meat may be permitted once a day, white rather more than black (see, 
however, p. 386). Celery, parsley, asparagus, and all irritants should 
be avoided. The patients should be encouraged to drink much water, 
alkaline waters to be preferred. All of these contain more sodium 
than potassium ; this latter having a greater affinity to uric acid, 
potassium bicarbonate, in daily quantities of from ten to twenty grains 
(0.6 to 1.5), may be given in Seltzer, Vichy, Bethesda, Poland, or 
Waukesha water, large amounts of which ought to be administered. 
The natural lithia waters contain less lithia than the occasion calls 
for; the lithium carbonate taken during a day ought to amount to 
from three to eight grains (0.2 to 0.5). Thus the artificial lithia 
waters, if carefully prepared, are preferable to those furnished by 
nature. Piperazin (and lysidin) may be given in three daily doses 
of from two to five grains (0.125 to 0.3) each. Urotropin is credited 
with the greatest solvent powers of all. In the test-tube it certainly 
has them. I gave it a long time, at alternating periods, to a child 
of two years. Without it, the uric acid appeared in the urine as a 
powder, with it in copious accumulations of needles. Urea, in a five- 
or ten-per-cent. solution, from one-half to one teaspoonful three times 
a day, deserves a trial. 

The presence of a stone in the kidney, besides giving rise to the 
symptoms enumerated above, may produce renal catarrh, and sec- 
ondary catarrh in the ureter and the bladder. When it leads to pye- 
litis or pyelonephritis, the treatment directed against their cause 
should be continued. At the same time gallic acid in daily doses of 
from eight to twenty-five grains (0.5 to 1.5) should be given, and 



PYELITIS. CYSTITIS 389 

balsamics (cubeb, copaiba) may be tried if the stomach permits. 
Methylene-blue (not pyoktanin) I have tried largely and persistently. 
It reduced neither the quantity of pus nor, whenever present, the alka- 
linity of the urine. In uncomplicated pyelitis the urine is apt to be 
acid. Saccharin deserves to be tried, from one to five grains daily. 
When the kidney is enlarged and pysemia threatening, surgical inter- 
ference is called for. Nephrotomy or nephrectomy may save life. 
Pyelitis, when resulting from tuberculosis, indicates nephrectomy as 
soon as the diagnosis is beyond doubt, and particularly when pus 
cocci are found, for they are more harmful than bacilli coli when 
causing pyelitis. 

2. The Bladder. 
Of cystitis, infancy and childhood exhibit every possible form, 
from the catarrhal to the ulcerous or diphtheritic; the tuberculous 
form is very rare in children. It is, however, more frequent than 
Ashby is willing to admit. Exposure to low temperatures, chilling of 
the parts by sitting on cold stones or wet grass, trauma, vulvovagi- 
nitis, the immigration of bacterium coli mainly during and after follic- 
ular enteritis, the administration of cantharides or other irritants, the 
drinking of beer, severe indigestion, constitutional diseases, such as 
pneumonia, gastro-enteritis, meningitis, typhoid fever, variola, or 
diphtheria, and the presence of stone in the bladder are just as many 
causes. Dysuria, retention or incontinence, vesical and rectal tenes- 
mus, the presence of mucus, pus, and blood in the urine, fever, and 
secondary peritonitis or " typhoid" symptoms are among the possi- 
bilities. Trauma demands absolute rest in bed, and either cold or 
warm applications, besides opium, which may be administered inter- 
nally or in suppositories; exposure (" cold") : warm bathing, diu- 
retics and a narcotic; the cystitis of infectious fevers: rest in bed 
and tonics; that following the use of cantharides (administered in- 
ternally or in vesicatories) : from two to ten grains of camphor 
(0.125 to 0.6) daily, internally; severe indigestion: the correction of 
the alimentary disturbances by abstinence, purgatives, and plenty of 
water ; hyperacidity of the urine : the use of alkaline waters ; hyper- 
alkalinity : that of hydrochloric acid ; vesical calculus : its removal, 
preferably by the suprapubic operation. In most cases the patient 
ought to be kept in bed, apply warm poultices, drink plenty of car- 
bonated alkaline water, abstain from cold beverages, live mostly on 
milk and farinaceous food, keep his body warm, particularly abdomen 
and feet, take a dose of calomel, and an opiate for occasional relief. 
But by far the best symptomatic remedy in the spasmodic pain of 
cystitis is hyoscyamus; from two to four grains (0.125 to 0.25) of 



390 DISEASES OF THE GENITO-URINARY ORGANS 

the extract may be taken daily for an indefinite period. The chronic 
cases of children of from three to six years require the internal use of 
boracic acid or potassium chlorate (from fifteen to thirty grains daily), 
turpentine, gallic or tannic acid, uva ursi, and salol or salicylates ; the 
latter if there be no nephritis at the same time. Urotropin in daily 
doses of from ten to thirty grains (0.6 to 2.0) is highly extolled. 
In a number of instances the local treatment of the bladder is indis- 
pensable ; the bladder may be washed out with sterilized warm water, 
or salt solution (6 to 1000), or a warm solution of boracic acid (two 
or three per cent.), or silver nitrate (one-quarter or one-half of one 
per cent.), or lysol (one-quarter of one per cent.). The silver nitrate 
irrigations should always be preceded and followed by those of warm 
water (not salt water), which are to be continued until it returns 
clear. This procedure requires sometimes, particularly in young chil- 
dren, anaesthesia by chloroform. 

Some of the symptoms met with in cystitis may occur without the 
presence of the latter. Painful spasm during micturition, retention 
of the urine, or incontinence is very frequent under the influence of 
quite a number of different conditions ; it is upon the causes that the 
treatment depends. Retention may be caused by a chronic spasm of 
the sphincter muscle, as in congenital or acquired stenosis. That, as 
well as paralysis of the bladder, may lead to retention, dilatation, and 
residual urine, with cystitis. Such a congenital stenosis bears the same 
relation to the bladder as the congenital stenosis (spastic or organic) 
of the pylorus to the stomach. The urine may contain besides a 
superabundance of uric acid, salts or bile, or irritants of a nature 
which cannot always be determined accurately. Thus, urticaria of 
the surface, when resulting from ingesta, is quite often complicated 
with vesical spasm, so that it appears that the same cause acts simul- 
taneously on the external and internal integuments. Dysuria may 
also depend upon a painful condition of the urethra resulting from 
acidity of the urine, or the transmission of a vulvo-vaginitis, or con- 
genital contraction of the urethral orifice, or adhesion (mostly ac- 
quired) of the labia majora, which is easily corrected, or a balanitis 
resulting from the irritating effect of urine retained round the glans 
penis by phimosis. The indications for treatment in all of these 
cases are so plain that the enumeration of the etiological factors seems 
to be sufficient. There are also cases of irritable bladder, as well 
in the young as in the adult, in which the result of the treatment 
gives sometimes the explanation of the cause. In a few cases the 
introduction of a catheter was sufficient to relieve the spasm of the 
neck, in others the administration of hyoscyamus proved satisfactory 



INCONTINENCE. RETENTION. IRRITABLE BLADDER 391 

(from one to three or four grains daily, according to age), or camphor 
with hyoscyamus or opium, or monobromated camphor, from two to 
eight grains (0.125 to 0.5) daily. A sufficient dose of codeine for the 
night. But the diagnosis of " irritable bladder" is too often made to 
cover ignorance of local diagnosis. 

Retention of urine by local atony and paralysis is rare in children, 
except as the result of hyperextension during school hours; still, it 
may occur in the course of spinal diseases. Now and then there are 
mechanical obstacles. In the newly-born the colliculus seminalis is 
often quite large and requires the introduction of a sound. Large 
stones in the bladder, or a smaller one near the neck, or one impacted 
in the urethra, or a string tied round the penis and buried in the 
swollen tissue, or the epithelial closure of the urethral orifice, or an 
cedematous prepuce are more or less amenable to a diagnosis and 
speedy amelioration. The injection of warm or cold water into the 
bladder, warm bathing or hip-bath, the correction of the epithelial 
adhesion of the prepuce, and the use of the catheter or sound find 
their ready indications. Retention during infectious or cerebral dis- 
eases requires great attention. Unconsciousness is a frequent cause, 
and frequent percussion of the bladder ought to be resorted to when 
the brain becomes insensible to the expansion of the organ. 

Evidently the causes of retention are very numerous ; one of the 
most puzzling cases was that in which the accumulation of urine was 
very great. The introduction of an elastic catheter, though it entered 
to its full length, availed nothing; a metal catheter entered with diffi- 
culty until it suddenly appeared to overcome an impediment and the 
urine was expelled with great force. The autopsy gave the explana- 
tion of the singular occurrence. The whole bladder was lined with 
a thick diphtheritic membrane, which was easily detached but did not 
admit the elastic catheter. This was deflected along the wall of the 
bladder, while the silver catheter succeeded in perforating the pseudo- 
membrane of the diphtheritic cystitis. 

The great variety of the causes of incontinence of urine requires 
tact and discrimination in the election of remedies. If there be an 
excess of urine, its cause (diabetes, brain disease) should be looked 
after. General anaemia and muscular debility, rhachitis, and tuber- 
culosis indicate a diet carefully selected for its nutritiousness and 
digestibility. Gentle massage of the whole body, sponging with alco- 
hol and water ( 1 to 6) or with water, and efficient friction with thick 
towels, sea-bathing, and the use of medicinal roborants, such as iron 
or arsenous acid, will always prove beneficial. The elixir pepsini, 
bismuthi, et strychnine of the National Formulary is a good prepara- 



392 DISEASES OF THE GENITO-URINARY ORGANS 

tion in insufficient gastric digestion, with atony of the stomach; a 
child of three years may take a teaspoonful three times a day. Many 
a case, mainly in neurotic families, requires persistent treatment for 
neurasthenia; several continued to adolescence, and could not be 
cured until the young women were sent to strangers, away from 
the influence of their neurotic families. Many a case of incontinence, 
however, that appears to be functional only, is really the organic 
result of a local cystitis or urethritis (Fr. Bierhoff in Festschrift). 

Attention should be paid to the capacity of the bladder. In every 
case, particularly in the evening, the quantity of fluids allowed should 
be restricted. The sigmoid flexure and the rectum should be empty 
at night, and the patient should be encouraged to evacuate both bladder 
and rectum before retiring. After a few hours' sleep the children 
ought to be taken up and roused sufficiently for both purposes. 

Muscular debility of the neck of the bladder (sphincter) requires 
general and local stimulation. The child should be encouraged to 
hold the urine as long as possible. Strychnine or other prepara- 
tions of nux vomica prove effective to a certain extent by improving 
both the general innervation and the appetite; in desperate cases 
an occasional subcutaneous injection into the perineum (from one- 
fortieth to one-sixteenth grain) has rendered good service; an oint- 
ment of one part of extract of nux vomica in from ten to sixteen parts 
of fat, introduced into the rectum (size of a coffee or lima bean) 
several times daily, will also act well and may be continued for some 
time. The same indication is fulfilled by ergot, the fluid or the solid 
extract of which may be employed internally. The interrupted elec- 
trical current is perhaps the most powerful local stimulant; one of 
the electrodes is applied to the perineum, the other to the hypogas- 
trium or the lumbar region. Maybe the psychic effect of the appli- 
cation is as effective as the current itself. The advice to apply the 
negative pole to the interior of the urethra or bladder and the positive 
somewhere externally is bad because of the danger of urethritis and 
cystitis. It is particularly in those cases in which the sphincter is liable 
to be overcome that the raising of the pelvis (by pillows, by raising 
the foot of the bed) has been recommended. The method is quite 
clever from a mechanical point of view, but the patients are not 
patient enough to sleep that way. 

Whenever there is oxalic acid or sugar, or an excess of urates and 
phosphates, or bacteria in the urine, the source of the disturbance 
should be attended to. Excess of uric acid (uricemie, Jules Comby 
in Festschrift) is often found in gouty, obese, asthmatic, diabetic, or 
neurotic families. A moderate diet of white meat, fish, eggs, milk, 



INCONTINENCE 



393 



farinacea, and fruit is recommended. No constipation must be per- 
mitted. Much water (alkaline) and hygiene of the skin (cold water). 
The digestive disorders forming the source of the anomalous condi- 
tion require a corresponding change in the diet (diminution of nitroge- 
nous food) or correction of the functional disorders of the stomach 
and liver by dilute hydrochloric or nitrohydrochloric acid and an 
occasional purgative. Until that can be accomplished the prognosis 
is very uncertain. Vesical catarrh, nephritis, and the presence of a 
calculus in either the kidney or the bladder have their own indications. 
From the latter it is removed by the suprapubic operation. The 
hyperesthesia of the body of the bladder, complicated or not with 
catarrh, — it is often found without it, — requires belladonna or its 
alkaloid. Both belladonna and atropine are tolerated in much larger 
doses by children, in proportion to their size or age, than by adults. 
In many cases a single evening dose of extract of belladonna (gr. J4 
to 24 to i = 0.015 to 0.06) or atropine sulphate (one-one-hundredth to 
one-seventy-fifth) answers well, sometimes to an unexpected degree. 
Potassium bromide (grs. 6 to 25 — 0.4 to 1.75), chloral hydrate (grs. 
2 to 10 = 0.1 to 0.6), camphor (grs. 2 to 5 = 0.125 to 0.3), extract, 
humuli fluidum (minims 4 to 10), the elixir humuli of the National 
Formulary, in teaspoonful doses, given at bedtime, or tinct. rhois 
aromat., from ten to fifteen drops several times a day, answers a similar 
purpose. 

Causes of reflex contraction located in the vagina, penis, or rectum 
require local correction. Vaginal catarrh is as obstinate because of 
its inaccessibility as it is frequent. Polypoid excrescences about the 
vagina or, in the urethra (of the female) demand removal; if there 
be phimosis, circumcision is required. But a great many cases which 
are presented for that purpose can easily be remedied by gentle dila- 
tation of the prepuce. Firm adhesion of the prepuce requires careful 
detaching. Pruritus of the sore surface, depending on rancid smegma 
or decomposing remnants of urine, requires bathing, cleanliness in 
general, and boric acid powder. Intestinal worms must be expelled, 
and the fact remembered that oxyuris has its original seat in the 
upper part of the colon and the lower part of the ileum, so that 
rectal injections have but a temporary effect in most cases. Fissure 
of the rectum, mostly of small size and located posteriorly, requires 
forcible dilatation, — a procedure which demands little time and gen- 
erally no anaesthetic, but is very efficient. 

Irritability of the neck of the bladder and the prostatic part of the 
urethra has been treated by Henry Thompson with cauterization by 
means of a two-per-cent. solution of silver nitrate. A solution of one 



394 DISEASES OF THE GENITOURINARY ORGANS 

part in a thousand of distilled water will be found sufficient, or a 
solution of one or two parts of tannin or alum in a hundred. General 
urethritis does well with protargol (from one-half- to two-per-cent. ) 
irrigations. Still, it is a better plan to introduce either an elastic cath- 
eter or a metal sound into the bladder, every few days, for two or four 
minutes. A few drops of a two- or three-per-cent. cocaine muriate 
solution instilled into and distributed in the urethra a few minutes 
before the insertion of the instrument will in many cases render gen- 
eral anaesthesia superfluous. The latter, however, cannot always be 
dispensed with. In the case of a girl of three years, with chronic 
catarrh of the bladder and incontinence, anaesthesia was required a 
dozen times, for two purposes, — first, to inject a solution of silver 
nitrate ( i to iooo) into the bladder, and, secondly, to dilate forcibly, 
with increasing amounts of water, the organ, which had habituated 
itself not to hold more than a few drachms of fluid at a time. This 
forced dilatation under anaesthesia I had to resort to in several cases, 
with fair results. 

Masturbation, which is so frequently the cause of irritation of the 
prostatic portion and thereby of incontinence, has its own indications 
(p. 403). Bodily punishment will avail but little in the treatment of 
incontinence from whatsoever cause, except in the diurnal form, when 
the boy refuses to give up his game, being either too much interested 
or too indolent. 

In a number of cases the removal of adenoid growths or the re- 
section of greatly hypertrophied tonsils has relieved incontinence (F. 
Huber and others). 

Tumors of the bladder (sarcoma, myxosarcoma, fibroma, dermoid) 
require suprapubic extirpation. The suprapubic operation has also 
superseded lithotrity in vesical calculus (incontinence or retention, 
sometimes sudden interruption of micturition, pain in rectum, peri- 
neum, or glans penis, rarely haematuria or cystitis). 

3. Other Organs: Anomalies and Diseases. 

The development of the genital organs begins in the sixth week of 
embryonic life; that of the urorectal septum, by which the urethra 
of the penis is formed, about the middle of the third month. About 
the same time the anterior part of the urethra is developed by the 
invagination of the epidermoid integument of the glans penis. This 
invagination extends backward to the valvula Guerin in the fossa 
navicularis. Here, where the two parts of the urethra are to meet, 
the opportunity is furnished for the occurrence of many anomalies. 

The invagination may not take place at all. In that case there 



TUMORS OF THE BLADDER. URETHRA. PREPUCE 



395 



is no indication of an anterior urethra. There may be a superficial 
epithelial obstruction of the urethra after it has been formed, with 
retention of urine behind it; or a partial contraction or narrowness 
of the external orifice, particularly in cases of genuine phimosis ; or 
a genuine stricture in the pars cavernosa, of which instances have 
been reported by Guyon, Englisch, and Demme; or an extensive 
obstruction mostly complicated with rectal anomalies, and retention 
of urine, dilatation of the ureters and renal pelves; or, finally (in a 
few reported cases), obstruction of the neck of the bladder, with the 
same disturbances unless the urachus be forcibly kept open. 

The emission of urine begins about the middle of foetal life. 
Sometimes the connection of the two parts of the urethra has not 
been established; in that case there is a dilatation behind the fossa 
navicularis with a constantly growing lake of urine. Its pressure 
may succeed in breaking through the obstacle with or without the 
formation of a valve, or it will burst the lower wall of the urethra 
behind the obstacle and cause a mild form of hypospadias. If the 
urethra be perforated farther back, the hypospadias may be scrotal 
or perineal. That hypospadias may occur in this way, and not only 
by an arrest of development, is proven by the occurrence of cicatrices 
and such contraction as depends on cicatrization only. 

Many of these anomalies are the subjects of surgical interference. 
Fortunately, all of them are rare, as the careful reports gathered 
by Kauflmann in " Deutsche Chirurgie," and Bohn in " Gerhardt's 
Manual" will prove. A double urethra was described by Englisch 
( 1895). Epithelial obstruction of the external orifice can be remedied 
by puncturing and dilatation; one such case I have seen thirty-five 
years ago, and never since. Membranous obstruction in the fossa 
navicularis has been pierced; even a case of foetal imperf oration 
of the whole glans penis has been perforated by Rauchfuss with 
apparent success. Congenital strictures have been treated with bou- 
gies. The narrow orifices of hypospadias should be dilated with 
bougies, or the knife, or both, and laminaria tents used to render 
the effect permanent. And hypospadias has been greatly benefited by 
operative procedures, with better success in modern times than the 
plastic operations of Dieffenbach could boast of (Carl Beck). 

The prepuce begins to be evolved about the end of the third and 
the beginning of the fourth month of embryonic life. Within a 
month afterwards it extends to the middle of the glans. Its cover- 
ing epithelia are pavement. They form from six to eight superjacent 
layers, and extend as far as the urethra and sometimes into the fossa 
navicularis. Thev also constitute the more or less numerous accu- 



396 DISEASES OF THE GENITO-URINARY ORGANS 

mulations, principally near the corona glandis, which were formerly 
taken to be fat, the so-called epithelial pearls. They are met with 
as early as the fifth month of foetal life. They are sometimes so large 
as to raise the adjoining part of the prepuce from the surface of the 
glans and to form small cavities around themselves, thus contributing 
to the spontaneous separation of the preputial adhesions. 

These adhesions are vastly more frequently soft agglutinations 
than solid unions. The causation is simple: as the prepuce and 
glans are in close juxtaposition, the epithelia of both remain moist, 
and thus become coherent. It is only in those cases in which the 
prepuce does not snugly cover the glans — for instance, in hypospadias 
and epispadias — that no, or but partial, cohesion takes place. There 
are cases, however, in which the union of the two surfaces becomes 
quite firm, partly in consequence of the occurrence of an inflamma- 
tory exudation, and partly because of the existence of an extraordinary 
number of superficial papillae, which, according to Englisch, grasp and 
join one another. Thus the soft cohesion of the prepuce and glans 
penis is a physiological condition, and therefore met with in almost 
every male child. The degree, however, to which it is developed is 
liable to differ. The prepuce of the newly-born being long, it may 
cover the whole glans down to the orifice of the urethra, and then by 
its overlapping adhesion give rise to retention of urine, and, in conse- 
quence of irritation by urine, and of the traction invariably connected 
with the slightest changes in the shape of the organ during micturi- 
tion, to pain, redness, muco-purulent secretion, sometimes moderate 
extravasation, and erections which again produce a local irritation of 
the surface. It is the erections, when frequently repeated, and when 
occurring more normally in later years, combined with the effects of 
the cavities formed round the epithelial pearls, which usher in the 
gradual and final separation of the prepuce from the glans penis. 
That process takes place between about the ninth and thirteenth years 
of life. Thus, in the vast majority of cases, no interference is re- 
quired. The more gradual the separation takes place the safer it 
proves. It is only artificial disjunction which may become a danger 
by secondary changes. The only reasons for interference are reten- 
tion of urine and balanitis, both of which are often found together. 
In most cases the separation is accomplished quite easily by holding 
the glans gently but firmly between the fingers and pushing or pulling 
the prepuce in the direction of the corona. Towards the end of the 
operation the pearls make their appearance; the separation, however, 
must be completed without interfering with them, and the prepuce 
then carried forward again to avoid paraphimosis ; for there will be 



PHIMOSIS 



397 



some slight oedema by which the latter might be occasioned. Before 
that is done, the application of vaseline, or zinc or lead ointment, or 
a dust of boracic acid, or bismuth subcarbonate, or a mixture of one 
part of salicylic acid, fifteen of bismuth, and twenty of talcum, is 
advisable. Carbolic acid is contraindicated because of its tendency 
to facilitate bleeding, though that be ever so slight. In most cases 
it is best not to repeat the procedure for some time, in order not to 
disturb the healing and hardening process. Every wound or tear 
may bring on cicatrization and secondary phimosis. In some cases 
the separation does not take place quite readily; in them a blunt 
probe introduced between the two layers will overcome the obstacle. 
Probe and fingers will succeed, if care and time be taken, not only in 
accomplishing the end in view, but also in avoiding tearing, bleeding, 
oedema, and inflammation. The occurrence of cicatrization is always 
a serious matter. I have succeeded without it in many more cases 
than I could take notes of; for the number of cases in which the 
medical man is consulted in reference to the advisability of circum- 
cision — which is one of the modern onslaughts upon the genito- 
urinary organs — is very great. Twenty-nine out of thirty alleged 
cases of unconquerable phimosis are exactly of the kind in which a 
patient reduction and separation prevent both a surgical operation 
and a surgical fee. The solid cohesion which requires the use of the 
knife and a careful and expert operation is very rare ; I have seen 
but few that were complete in a lifetime. I cannot imagine that a 
total synechia is curable without a plastic operation or, better still, 
the total removal of the prepuce after its separation; for new adhesion 
must follow the operative separation in the absence of mucous mem- 
brane. 

From what I have said it follows that we cannot recognize the 
existence of an actual phimosis in the young before an attempt has 
been made to relieve the epithelial agglutination. The actual cases 
may exhibit a long or a short prepuce, be partial or total, congenital or 
acquired, atrophic or hypertrophic. The latter species is often depend- 
ent on changes in the internal lamina of the prepuce, which, when orig- 
inally contracted and tight, is subject to inflammatory and exudative 
processes ; the atrophic form is due more frequently to a defective de- 
velopment of the integument, which thereby becomes attenuated. 
Both of these forms are liable to be congenital, and either is found as 
well among infants and children as in later life. The degree of the 
phimosis depends upon the development of these anomalies, and also 
upon the degree of the presence of the elastic layer described by Reiner 
and situated between the two laminae of the prepuce. 



398 DISEASES OF THE GENITO-URINARY ORGANS 

Phimosis may be acquired by pathological changes of the tissue 
depending on accidental morbid processes. Dropsy may so swell the 
prepuce as to result in it. The frenulum, congenitally short or other- 
wise, may suppurate and cicatrize. Inflammation and ulceration from 
whatever cause, irritation and tears following inconsiderate or unsuc- 
cessful attempts at separating epithelial adhesions, and the cicatriza- 
tion of circumcision wounds are apt to render the edges of the prepuce 
unduly rigid. 

The symptoms of phimosis may be both local and general. Irri- 
tation by contact with urine and pouching of the prepuce by mechan- 
ical retention are quite frequent. Smegma becomes rancid when the 
original epithelial adhesion has been separated. Retention of urine, 
or incontinence, or both combined, is often met with. The former 
and the spastic dysuria produced thereby result in straining, vesical 
symptoms resembling those met with in vesical calculus, prolapsus of 
the rectum with more or less constant tenesmus, the protrusion of 
hernia, and the formation of struma. Like balanitis, which is fre- 
quent, cystitis and hematuria will occur. The local irritation gives 
rise to erection, sexual excitement, and masturbation in the young- 
est of infants. Headaches are said to be frequent but mostly tem- 
porary, and permanent nervous symptoms in great numbers have 
been attributed to phimosis. It has become quite customary, though 
less so to-day than ten years ago, to attribute severe nervous de- 
rangements to it. A London neurologist has gone so far as to make 
the statement that in twenty-five cases of epilepsy he found con- 
genital phimosis eleven times. Probably it was the spurious variety 
of " phimosis," which may be reduced. The so-called reflex paraly- 
sis from genito-urinary causes has played and is still playing an 
important ( ?) part in American pathology. Numerous cases of in- 
fantile poliomyelitis and cerebral paralysis, spastic paraplegia and 
paralysis, chorea, epilepsy, contractures, and idiocy have been ex- 
plained (?) by the presence of phimosis. The numerous cases alluded 
to above of alleged phimosis, in which the separation of the pre- 
putial adhesion and apparent phimosis was easily accomplished, were 
frequently such as had been condemned to be operated upon for a 
serious spinal or cerebral disease. There was a time when, in a 
New York medical society, one of the sponsors of the theory of 
genito-urinary reflex paralysis and consecutive poliomyelitis related 
cases of contracture and convulsions. When reminded that his cases 
were convulsive and not paralytic, he retorted that he was no 
physiological theorist, but he cured his patients. In another meet- 
ing, years afterwards, I stated that I had never seen a case that 



PHIMOSIS 399 

obliged me to assume a causal connection between paralysis or con- 
traction on the one hand and phimosis on the other, and was sustained 
by neurologists of rank, who also denied ever having seen a case 
which necessitated the assumption of a genito-urinary etiology. Still, 
the bugbear is alive, many a prepuce is sacrificed, many a fee pocketed; 
many a diagnosis not made, and many a case either procrastinated 
or not cured. 

Most instances of moderate phimosis are best treated by the gentle 
method of gradual retraction, some are improved by the normal erec- 
tion occasioned by micturition and other causes. For these reasons 
dozens of years ago an experienced pediatric surgeon (Guersant) 
stated that he seldom operated for phimosis before the fourth or fifth 
year. Forcible dilatation, if resulting in fissures of the edge, must 
be frequently repeated to avoid hard cicatrization and consecutive 
contraction. Many such cases, however, are served better by circum- 
cision. Those which are not amenable to mechanical treatment re- 
quire the knife. The incision of the inner lamina alone, which has 
been recommended, is very apt to be incomplete, though painful, and 
to lead to swelling and imperfect results. The atrophic variety re- 
quires a dorsal incision by either a knife, carried on a director, or a 
pair of scissors ; the inner lamina is often not thoroughly divided, 
and requires the repetition of the incision; when the scissors cannot 
be carried over the whole length of the glans, it has become necessary 
to first cut down on the corona glandis to enable the operator to 
carry the scissors over the entire length. The cut edges are mostly 
subjected to Kocher's continuous suture, and the whole surface treated 
antiseptically with bismuth (dermatol) and an aseptic dressing kept 
moist with a mild antiseptic, boric or boro-salicylic (Thiersch's) solu- 
tion. Iodoform and carbolic acid should be avoided. The lower 
corners are mostly rounded off. This is particularly necessary in the 
cases of hypertrophic phimosis which are subjected to the same sur- 
gical treatment. Most of this class, however, demand complete cir- 
cumcision, care being taken that more is removed of the dorsal prepuce 
than of the opposite side, that the inner lamina is separately divided 
afterwards, and that the epithelial adhesion is carefully separated. 
The prepuce must be drawn forward sufficiently to protect the glans 
against being injured; more than once I have seen it mutilated. In 
one case the mutilated glans became infected with diphtheria. The 
wound must be sutured and treated antiseptically. One of the saddest 
cases of my whole life, and one of persistent distress, was the death 
from erysipelas from that simple operation performed on a boy of 
three years. Infections of circumcision wounds by bacteric poisons 



4 00 DISEASES OF THE GENITO-URINARY ORGANS 

are quite frequent; cases of diphtheritic invasions I have published 
in my treatise on diphtheria (1880), and before that in the second 
volume of " Gerhardt's Manual" (1876); many more I have seen 
since ; and syphilis and tuberculosis have been known to follow many 
instances of either surgical or, more frequently, ritual circumcision. 

Diphtheria of the prepuce, or rather of the genito-urinary organs in 
general, the female included, may occur as an originally local affection 
— such as those alluded to — or as a part of the general infectious dis- 
eases. The latter are mainly diphtheria, scarlatina, and measles. The 
last named is the very malady which appears to predispose the system 
to the most vehement forms of local invasions. The aphthous vulvitis 
of little girls, and noma, are mostly found after measles ; and diph- 
theria, when found after the same eruption, is more apt to destroy 
life, with general symptoms, than under ordinary circumstances. In 
many cases of localized diphtheria, however, the constitutional symp- 
toms are but few, provided effective local treatment is immediately 
resorted to. Absolute cleanliness of the parts (sponging and bathing) 
is first in order; after that, local disinfection. Applications of lime- 
water will suffice for mild cases; solutions of one or two parts of 
zinc sulphocarbolate in one hundred of water, or from one- to five- 
per-cent. solutions of aluminum aceto-tartrate in water, will act well. 
These two may be used to advantage as a vaginal injection in the 
case of the smallest girls. The nozzle of a small hard-rubber or 
glass syringe should be lengthened by a thin India-rubber tube, from 
half an inch to an inch long, which passes the hymen easily and 
permits an irrigation of the otherwise inaccessible parts. In many 
cases solutions of mercuric bichloride proved successful : for occa- 
sional applications, of one in from three to five hundred of water; 
for frequent use, of one in from two to five thousand. In exceptional 
cases, however, it is not well borne and frets the surface. Iodoform 
as a powder, or in from eight to fifteen parts of vaseline, has rendered 
very effective services. Boracic acid avails but little. 

Noma of the vulva and vagina requires more determined local 
treatment, besides assiduous roborant and stimulant administrations. 
Mineral acids in full strength or strong solutions of corrosive subli- 
mate have proved efficient in many cases in which the progress of the 
disease was not too rapid. I have had most successes with the actual 
cautery. Pyoktanin, when used in cases of noma of the face and of 
the vulva, was absolutely worthless. 

Paraphimosis results from manipulation. The separation of the 
epithelial congenital adhesion and the dilatation of a phimosis are 
liable to be followed by (Edematous swelling. In both cases the pre- 



DIPHTHERIA. NOMA. PARAPHIMOSIS. CATARRH 



401 



puce should be replaced over the glans. If that be omitted, the 
prepuce — relatively long in the child — will swell, and may become 
gangrenous. Fortunately, the penis itself is not often drawn into 
that process. For the purpose of reduction, the glans penis, which is 
considerably swelled, is persistently compressed while the prepuce is 
drawn forward. A good deal of force is sometimes required, and 
not infrequently an anaesthetic. Sometimes gradual compression by 
bandages (cotton or rubber) must precede the attempt at reduction; 
in some cases, however, a careful incision of the prepuce, the more 
careful when no director can be introduced between the glans and 
prepuce, is unavoidable to relieve the constriction. 

The treatment of the more common forms of balanitis and balano- 
posthitis, occasioned by the decomposition of smegma, or by mas- 
turbation, or gonorrhoea, or trauma, such as the constriction of the 
organ by a string, is not always quite simple. When there is much 
oedema it may become necessary to incise the prepuce to get at the 
sore surface. In most cases, however, astringent or disinfectant solu- 
tions can readily be applied either directly or through a small syringe. 
Solutions of lead acetate, zinc sulphate, alum, tannin, zinc sulpho- 
carbolate, or aluminum aceto-tartrate can be employed in different 
strengths, also potassium permanganate (1 to 1000 or 3000). Among 
the poor, when assiduous attention is out of the question, ointments 
or powders are preferable. Ointments for this purpose are best made 
with vaseline. Warm bathing and sponging with moist absorbent 
cotton will improve the chances of a rapid recovery. 

A similar local treatment is adapted to the vulvar and vaginal 
catarrh of both the adult and the infant or child. It is very common 
among the latter, and quite obstinate because of the comparative 
inaccessibility of the parts, no matter whether the catarrh is simple 
or specific. The latter occurs even in the newly-born; the causes 
of the former are very various. A predisposition may depend on 
that structural debility, with chronic inflammation of most tissues, 
which we are in the habit of calling scrofulous. Local exposure to 
cold, sitting on house-stoops, the irritation brought on by masturba- 
tion or by foreign bodies, — mud, cotton, carpet-fuzz, glass, wood, all 
of which I have found in the narrowest vaginae; also oxyuris emi- 
grating from the rectum, the use of soiled cloths and towels, and the 
gross neglect of the most urgent cleanliness, with the possibility of 
directly importing bacteria coli, are among the most frequent causes 
of vaginal catarrh. Specific vaginal catarrh (gonorrhceal colpitis 
with its diplococcus and others) is by no means rare. The infection, 
though most often indirect, and conveyed by towels, bed-sheets, but 

26 



4 02 DISEASES OF THE GENITO-URINARY ORGANS 

also by immediate bodily contact (mostly in institutions which furnish 
those cases in large numbers as a dispensation of providence), fre- 
quently gives rise, even in the smallest children, to glandular swell- 
ings, endometritis, parametritis, salpingitis, oophoritis, and peritonitis, 
also to urethritis, though the latter appears to be less common in 
children than in adults. Endometritis with its results is liable to be 
very obstinate; for while the cervix is growing in length up to the 
fifth year, the endometrium remains folded upon itself many times. 
Only between the ninth and tenth years (not always then, so that 
dysmenorrhea may depend upon this infant condition of the uterus) 
are these folds smoothed out. Thus the great danger of a gon- 
orrheal endometritis becomes evident. The treatment of urethritis 
is not necessary when (as happens frequently) the urethra takes no 
part in the gonorrhoea of the vagina. That contagion should take 
place through the air, according to Bouchard, I have never been able 
to observe. Besides the local treatment, in conformity with the de- 
tails given above, absolute cleanliness of the body and clothing and 
frequent (general and hip) baths are required. Masturbation must 
be guarded against and foreign bodies sought out and removed. 
Rectal oxyurides require injections with water, vinegar and water, 
garlic decoctions, or cod-liver oil. They must be resumed after an 
intermission of weeks because of the repeated immigration into the 
rectum from the upper parts of the intestine, where the nematoid has 
its habitat. In gonorrhceal cases the transmission of the virus to 
the eyes and to other persons must be guarded against. To reach 
the recesses of the vagina, partial or total removal of the hymen has 
been advised ; "but I have met with no such brutal indication. Be- 
sides the solutions enumerated above, silver nitrate has been ad- 
vised. I have used it, in solutions of one in from five hundred to 
a thousand, in a number of cases of ulcerative catarrh, also argonin in 
from one- to three-per-cent., or protargol in one- to two- or more per- 
cent, solutions. In some the restitution of the superficial losses of 
substance appeared to be more rapid. In stronger solutions and 
solid it has been employed in tubercular ulcerations, in reference to 
which I have no experience. In many cases of vaginal catarrh the 
surrounding parts are sore and suppurating, or eczematous. Lead or 
bismuth ointments, or bismuth powder, with or without salicylic acid, 
will effect a cure in that complication. 

A frequent result of vaginal catarrh of long standing is a mod- 
erate degree of atresia of the vagina. It is usually of a superficial 
character only, and can be remedied by tearing the adhesion with 
both hands, or by piercing with a probe and dilating the artificial 



ATRESIA. VAGINAL HEMORRHAGE. MASTURBATION 



403 



opening. Astringent applications, or those of dermatol ointment 
(1 to 6 or 8), will prevent the renewal of the closure. Diphtheritic 
inflammation of the vulva and vagina I have known to result in pretty 
firm occlusion. In one case the reopening required some force and 
the continued use of bougies and astringent applications to prevent 
a repetition of the union. The imperforate condition of the hymen, 
mostly congenital, is often the same process of epithelial and inflam- 
matory cohesion accomplished during foetal life. According to its 
early or later formation, and according to the presence or absence of 
vaginal complications, it requires either the probe or the knife. Such 
a complication is mostly the result of either an arrest of development 
or an inflammatory malformation. An early adhesive inflamma- 
tion of the vagina will obstruct it in its entire length, or a transverse 
obstruction of the ducts of Miiller may result in an absence of the 
vagina below the external os uteri. 

Vaginal hemorrhage of a mild degree has been observed in the 
newly-born, without any complication, least so with bleeding from 
other organs. It is mostly very slight. In masturbating infants and 
children, and in some of those who suffer from a severe vaginal 
catarrh, some blood may be noticed. It requires no special treatment ; 
nor was there an indication or an opportunity to interfere in the 
very rare cases of genuine menstruation in the very young which 
have been reported. 

In connection with vaginal catarrh I mentioned masturbation as 
one of the causes. Still, it is not only a cause in some cases ; in 
many others it is its effect. Indeed, masturbation is so frequent that 
a few words on the subject may be deemed permissible at this place, 
in addition to my former discussion of the subject {Arch. Pea 1 ., April, 
1890, and Amer. Journ. Dis. Ch. and Women, 1875). That habit, 
like its precursor, the sucking of fingers, often semi-conscious, is 
very frequent in infants and children; more in girls of the earliest 
infancy, more in boys of advancing years, and there is a variety of 
causes leading to it. Such are local irritation (sometimes by nurses) 
of the genitals in the very youngest, excitation in those older, feather- 
beds, excess of animal food and stimulating beverages, rancid smegma 
under a long or a narrow prepuce, eruptions on the penis, vaginal 
and vesical catarrh, renal calculi, cryptorchis, preputial adhesion, 
phimosis, oxyuris, and constipation. Among remedies, I recom- 
mend the relief of the causes as enumerated and partly alluded to 
on previous pages : cooling diet and cool coverings, attention to the 
kidneys, bladder, and rectum, relief of external irritation caused by 
clothing, mainly by misfit trousers, immediate removal from the bed 



4 04 DISEASES OF THE GENITO-URINARY ORGANS 

upon awakening, no sleeping with bedfellows, cold bathing and 
sponging, mechanical prevention, and timely punishment. Long 
school hours and study, without long recesses, should be avoided. 
Allow no child to remain in his seat during recess ; see that he has his 
hands on the table and that his body is visible. Give him no side 
pocket in his trousers. Teach him with an occasional remark, but 
do not harp on the subject to any length. Watch protracted conva- 
lescence with its constant lying abed while awake. Those who ride on 
horseback or on the bicycle should be watched; some will have erec- 
tions at once. Goltz places the erection centre about the fourth lum- 
bar vertebra, others in the pedunculi cerebri and medulla oblongata. 
When there is a central disease, treatment may be useless. Even 
operations like clitoridectomy, or the application of vesicatories, have 
no effect on them. A girl of nine years was masturbating almost 
constantly by directing her mind to her voluptuous sensations, and 
admitted that she would not stop, i, -Such bad cases cannot be reached 
by medication. It consists in ample doses of camphor, monobromated 
camphor, lupulin, bromides; also in a sufficient dose of chloral hy- 
drate for children that sleep interruptedly (hypnotism?). 

Cryptorchis is the absence of the testicle from the scrotum. Nor- 
mally it descends in the ninth month of utero-gestation, or during the 
first weeks of extra-uterine life, but sometimes at a later period, or 
not at all. In the latter case, particularly when incarcerated in the 
canal, it is apt to undergo in later life malignant degeneration. When 
in its descent it gets under the femoral arch, resembling a crural 
hernia, or to the perineum, it is subject to inflammation, and requires 
the application of ice, and occasionally a local depletion, or a puncture 
for the relief of effusion, and sedatives for the removal of reflex 
convulsions. In most cases of incomplete descent the testicle is found 
in the inguinal canal, and slightly movable; it may be complicated 
with hernia. No matter whether this complication is present or not, 
the treatment consists in the application and constant wearing of a 
truss so adjusted as to keep the testicle below and the intestine above. 
Its effect can be enhanced by frequent and gentle massage. This 
simple treatment, if started very early, I have found effective in so 
many cases that Ashby and Wright's advice — not to rely on it, but 
to operate and either fix the testicle below or remove it altogether — 
appears to me inappropriate in the very young. If, however, a result 
has not been accomplished in time, or if no attention was ever paid 
to the anomaly, it should be urgently advised to perform orchido- 
pexy between the tenth and fourteenth years (before puberty), or 
earlier if there be a hernia. If that be done, the testicle will develop ; 



CRYPTORCHIS. ORCHITIS. HYDROCELE 405 

if not, its atrophy is inevitable, or malignant degeneration may take 
place. 

Orchitis is occasionally found in children. The acute form is 
either traumatic or alternates, even in the infant, with parotitis, or 
no cause is obvious. The treatment must be conducted on general 
principles, and consists in the local use of ice, of purgatives, and, 
occasionally, of antipyretics and narcotics. Leeches resulted, in a 
few of my cases, in extensive swelling of the scrotum. Chronic 
orchitis is mostly combined with epididymitis, the result of trauma 
combined with a scrofulous disposition. It is apt to lead to indura- 
tion, caseation, and tuberculization. If that occurs, the organ ought 
to be removed to avoid general tuberculosis. 

Primary tuberculosis appears to begin mostly in the epididymis, 
and requires removal, as well as dermoids, sarcomata, and carcino- 
mata. Of the latter, I saw a case in a boy of four years. It was 
removed and no new local trouble arose ; not even in the lymph-bodies 
of the neighborhood. But the disease reappeared in the lungs. Both 
testicles and ovaries are more subject to congenital tumors than per- 
haps any other organ, with the exception of the kidneys. Wolff 
(Deutsche Zeit. f. Chir., 1899, vol. liii) collected two cases of sar- 
coma of the prostate under one year, three from one to ten, three from 
twenty to thirty. Secondary (?) miliary tuberculosis was observed 
by Neureutter (C. Springer in Zeit. f. Heilkunde, 1902) in the vagina 
complicated as follows: with universal tuberculosis (girl of four- 
teen), with tuberculosis of the uterus and tubes (girl of eight), with 
that of the uterus, tubes, lymph-bodies, intestines, lungs, and larynx 
(girl of eight). 

Syphilis of the testes requires a strict antisyphilitic treatment. 
There is the indication for the internal administration of mercurials 
and iodides; in the first few weeks a daily hypodermic injection of 
a soluble mercurial salt will improve the chances of recovery. 

Hydrocele is of frequent occurrence. A few drops of serum are 
normally found in the tunica vaginalis propria. Larger accumula- 
tions of serum are met with in more than ten per cent, of all male 
infants, — mostly on the right side, seldom on both. In the majority 
of cases there is no longer a communication with the abdominal cav- 
ity. When it remains, a hernia may complicate the hydrocele, and 
the diagnosis may be more difficult because, in such a case, the fluid 
is apt to return occasionally into the abdomen. Spontaneous absorp- 
tion is not very rare, but suppuration uncommon. I have injected 
alcohol and diluted tincture of iodine, and setoned the scrotum with 
either silver wire or silk. All of these methods are bad to begin 



4 o6 DISEASES OF THE GENITOURINARY ORGANS 

with. Simple punctures, one or more, made once or repeatedly with 
a sterilized needle or trocar, will allow the escape of the fluid, which 
frequently does not return after the first procedure. It is best to 
dislodge the integument a little, so as to have no direct escape of 
the serum. If there be a relapse, however, after a number of punc- 
tures, the injection of a small amount of tincture of iodine, or of 
Lugol's solution, or of two or three drops of carbolic acid, after the 
fluid has been withdrawn, will prove successful. Radical operations 
are rarely required. The cases in which the communication with 
the abdominal cavity is still patent require the application of a truss 
after the serum has been allowed to return to the abdomen, or a 
radical operation (Bassini). 

A hydrocele of the spermatic cord is either congenital (the result 
of non-conglutination of the pars vaginalis peritonaei) or caused by 
an inflammation of the tunica vaginalis, of the testicle, or of the sper- 
matic cord. It may be let alone or the fluid aspirated. 

The pseudoplasms of the young female urogenital organs offer 
no special indications of their own. Tumors of the ovaries were 
mostly found, on operation, to be dermoid cysts, and very rarely carci- 
nomatous or tubercular. The latter and sarcoma, of which d'Arcy 
Power collected from literature twenty-five cases (St. Barthol. Hosp. 
Rep., vol. xxxi), are rare occurrences in the young vagina. Cysts 
have sometimes been found above the hymen, and soft polypi more 
frequently in the urethra. They are either easily recognized or mis- 
taken for a simple prolapse of the urethral mucous membrane. They 
sometimes give rise to vesical tenesmus and dysuria, and also to 
(mostly slight) hemorrhages. Evulsion, chromic acid, the scissors, 
and the actual cautery, now and then two of these means combined, 
have been used. Ligature never succeeded in my hands. It would 
always cut through at once, produce some bleeding, and necessitate 
some other method. 



IX 

Diseases of the Respiratory Organs 

I. The Nares. 
Acute nasal catarrh* (acute catarrhal rhinitis) is found either 
as a sporadic or an epidemic ailment; the latter rarely depends 
on erysipelas, still less frequently on gonorrhoea, more frequently on 
influenza, measles, or whooping-cough. The mere presence of numer- 
ous microbes of different varieties is of no account; so long as the 
surface is fairly intact, the nasal mucus is bactericide to a great 
extent, and invasion does not mean infection. The sporadic form 
is sometimes local and unilateral; in that case it has a local cause, 
such as a traumatic lesion or a foreign body ; when bilateral and gen- 
eral, it is mostly the result of sudden thermometric or barometric 
changes, or exposure to dust, impure or dry furnace air, etc. In rare 
cases the irritation of trifacial branches of the maxillae will, when 
dentition is really abnormal or unusually difficult, give rise to vaso- 
motor and secretory changes of the nasal mucous membrane, which 
is supplied with ramifications of the same nerve. Acute nasal catarrh 
may be attended by high temperatures, considerable swelling, and 
obstruction (thus rendering respiration extremely difficult, particu- 
larly when the patient is newly-born or quite young), and by second- 
ary affections, such as swelling of the cervical lymph-bodies, acute 
pharyngitis, amygdalitis, conjunctivitis, otitis, headaches, and sleep- 
lessness. The indications for treatment are various : the local hypere- 
mia and swelling are to be reduced, the secretion removed, the fever 



* According to R. O. Neumann (Zeitsch. f. Hyg., vol. xl., 1902), the normal 
nose contains a large number of microbes : micrococcus pyogenes albus in from 
eighty-six to ninety, and the bacillus pseudodiphtherise in ninety-eight per 
cent, of all cases. In nasal catarrh there is a relative increase of the bacillus 
pneumoniae of Fraenkel and of Friedlander, of streptococcus pyogenes and of 
the bacillus of diphtheria. The bacillus pseudodiphtherise is a saprophyte only, 
and has no relation to nasal catarrh; but virulent bacilli of diphtheria (and 
those of Fraenkel) may cause it. Thus my statement that many cases of nasal 
catarrh during an epidemic of diphtheria were diphtheritic — first based on 
clinical observations in i860 (Amer. Med. Times) — is confirmed by the most 
recent bacteriological researches. 

There appears to be no specific cause of nasal catarrh, as might be ex- 
pected. 

407 



4 o8 DISEASES OF THE RESPIRATORY ORGANS 

relieved, and secondary affections either prevented or treated, among 
them all those occasioned by the unfiltered condition of the air 
admitted to the respiratory organs through the mouth. 

Hyperemia and swelling may prove dangerous to very young- 
babies. In them the nasal cavities are narrow, and so easily ob- 
structed by an acute catarrh that now and then a newly-born infant 
that has not yet learned how to breathe through the mouth, in which 
the tongue is curled up, is in danger of suffocating. That narrowness 
is universal. In the newly-born and the infant the lower concha closely 
hugs the lateral wall and contracts the lower nasal meatus. The 
middle nasal duct is somewhat larger and straight, almost obstructed 
in front, and circular (very much smaller and more irregular than 
in the adult) ; the anterior blunt end of the middle concha lies on 
the upper margin of the lower. The whole nasal cavity is narrow. 
At the level of the eyes the latitude of the nasal cavity compares with 
the width of the face as one to three and a half in the adult and only 
one to four and a half in the newly-born. In him the septum is 
more horizontal, in the adult almost vertical. The antra are scarcely 
perceptible, with a narrow slit in place of the nearly spherical orifice 
of the adult. Of congenital obstruction by ossification of the posterior 
nasal orifice Boulay collected sixty cases (Rev. Mens., 1901). The 
only relief is by operation at a rather later period of life. 

Some of the cases of acute rhinitis require constant attention; 
day and night the mouth must be kept open by gentle pressure on 
the chin to enable the little patient to breathe through the mouth 
until the nares become pervious. Particularly in cases in which the 
mucous membrane is thickened from birth, or a nasal polypus is 
present, or a swelling of the pharyngeal or the palatine tonsils, and 
adenoid enlargement, the danger of suffocation is great. In a single 
case I have been compelled to repeatedly apply the galvano-cautery 
to the left nasal cavity of a newly-born whose acute catarrh ob- 
structed the narrow channel. Astringent solutions are indicated for 
a similar purpose, or ointments which may be applied by means of 
a camers-hair brush. Still, I cannot express much satisfaction at 
the effects obtained, for the reason that whatever is not quite indiffer- 
ent to the mucous surface will irritate and increase the trouble. 
That is what is done by high or low temperatures of an injection 
— a good medium is about 90 ° F. — and by most astringents unless 
in a very mild solution. Better is a two-per-cent. solution of cocaine 
hydrochlorate, which may be applied with a brush or by means 
of the atomizer, from time to time. A freshly prepared solution 
(suspension) of adrenal powder in water (from five to ten per cent.) 



CHRONIC NASAL CATARRH 409 

will not cause the secondary hyperemia following the use of co- 
caine. Camphor inhalations have been praised, and powder contain- 
ing a few per cent, of menthol. The secretion must be removed 
now and then by wiping out the nose and bringing on sneezing. 
The wiping out may be done with a probe covered with absorbent 
cotton, the latter to be introduced horizontally, either dry or moistened 
with an alum or cocaine solution. The passage may also be kept 
open by a physiological salt solution (1 to 150), or an astringent, 
or a disinfectant wash of alum, zinc sulphate, bismuth subcarbonate, 
or boracic acid. The latter is not always satisfactory. In most cases, 
it is true, it acts very mildly, but now and then I have seen catarrhal 
secretions increased by it. These applications may be made in dif- 
ferent ways. An atomizer, when the nozzle is lengthened with a short 
piece of India-rubber tubing, will do no harm; nothing that is hard 
or pointed should be used for a nostril; injections should be made 
very gently and slowly, else they are liable to injure the ear; irri- 
gation by merely emptying a pipette or a small spoonful of a solution 
into the nostril will prove uninjurious, but not very efficient. As 
a rule, I prefer a nasal cup, which should not be emptied at once, 
so as to allow ample breathing time. In the newly-born, on account 
of the low condition of its reflex activity, snuff does not act so 
readily as it does in more advanced age; but it may be tried for 
the purpose of emptying the nares. Otherwise the rational general 
treatment of a catarrh may be resorted to: moderate temperature 
of the room (from 68° to 74 ° F.), moist air when the secretion is thick 
and viscid or scanty, an occasional warm bath, a dose of quinine 
about noon if there be a considerable rise of temperature in the 
afternoon, an occasional dose of phenacetin or antipyrin during the 
day or small doses of the tincture of aconite at intervals of two 
hours ; probably a single dose of opium as a sedative and diaphoretic, 
late in the evening. Dover's powder, from one to two milligrammes 
(one-sixtieth to one-thirtieth grain). 

Chronic nasal catarrh derives its therapeutical indications from 
its many occasional causes ; for instance, frequent returns of acute 
catarrh, dusty, cold, and moist air, also dry furnace air, the presence of 
a foreign body, or the deviation of the septum. This latter condition 
may be congenital, even hereditary, due to unequal development of 
neighboring, mostly the turbinated, bones. The vomer does not fully 
ossify until puberty, and is therefore long dependent on the facial 
bones, " whose evolution leads to irregularities in the higher races, less 
in the negro" (Kohts), or due to a fracture of the septum, or to its dis- 
ruption from the ethmoid, or vomer, or superior maxilla. It results in 



4 io DISEASES OF THE RESPIRATORY ORGANS 

obstruction, and behind it in accumulation of mucus which is disinte- 
grated and irritates. Other causes of chronic nasal catarrh are en- 
larged tonsils, chronic pharyngeal catarrh, and adenoid vegetations, 
with their damaging influence on respiration, digestion, the sense of 
smell and taste, and intellectual development. Scrofula, tuberculosis, 
and syphilis, with their effects on mucous membranes, bones, and car- 
tilages, are frequent causes of chronic nasal catarrh. Less frequent are 
the effects of furunculosis, which here is rarer than in the adult; 
of croupous inflammation; of diphtheria of the nose, which may 
be met with independently of pharyngeal diphtheria or may usher 
it in; or of eczema of the upper lip. 

Syphilis, tuberculosis, and scrofula have their own indications. 
Thus, a chronic rhinitis occasioned by them demands mercury, ar- 
senic, creosote, cod-liver oil, iron, or phosphorus, according to general 
rules. Abscesses are to be opened, the small necrotic bones removed, 
furuncles incised. They should be treated early, for cerebral embo- 
lism I have known to come from them several times in my life. The 
vascular connection is very intimate, for the anterior and posterior 
ethmoid veins enter the cavernous sinus either directly or by means 
of the superior ophthalmic vein. Foreign bodies must be extracted, 
adenoid vegetations removed, and hypertrophied tonsils resected or 
— in occasional cases — treated with the galvano-cautery. Many a case 
of chronic nasal catarrh will be relieved, or nearly cured, by these 
measures, or, on the other hand, there is many a case of chronic 
pharyngitis which gets well through the treatment of the nasal 
catarrh. Indeed, there are very many of these complications in 
which the determination of the primary seat of the affection is 
very difficult or even impossible. If there be a considerable deviation 
of the septum, not to speak of the excessively rare cases of bony 
union, it must be corrected. In very young infants that correction 
can sometimes be accomplished by manual pressure. The cleansing 
of the nasal cavities is of at least as much importance as in acute 
catarrh. They must be washed out from two to four times a day with 
some warm fluid. According to the case, this may be salt water, or 
a solution of boracic acid ( from two to four per cent. ) , or alum ( half 
per cent.). The same precautions should be used which were advised 
above. If larger quantities of the fluid be used, the injection should 
be made very gently and the child taught to keep his mouth com- 
fortably open. Potassium chlorate has been employed in solutions of 
from one to three per cent. ; resorcin, of two per cent. ; creosote 
has been applied similarly; iodine or tannin in combination with 
glycerin. Cocaine solutions have been employed with good results. 



CHRONIC NASAL DISEASES 411 

Their immediate effect is evident, and they are better than a merely 
temporary makeshift. What I have seen do a great deal of good is 
silver nitrate. A solution of 1 to 250 or 2000 may be sprayed into 
the nasal cavity once a day or every other day. When a carious 
bone is underlying the chronic catarrh, an iodoform ointment 
(1 to 8 or 15 vaseline) may be applied several times a day to 
advantage. Hypertrophy of the mucous membrane and submucous 
tissue, with ulcerations or granulations, adds greatly to the difficulties 
of the case. Lactic acid in powder or in strong solutions has the 
reputation of destroying morbid tissues, mainly granulations, and 
of leaving the healthy tissue intact. Still, I cannot say that it has 
rendered me very appreciable service in cases I considered adapted 
to its alleged powers. The exuberant tissue will, however, be bene- 
ficially influenced by an application every few days of a solution 
of iodine (1 to 8 or 1 to 4), of iodol or aristol, of bismuth sub- 
carbonate, of a strong solution (ninety per cent.) of carbolic acid 
every four or five days, of chromic acid once every week or ten days, 
and last and best, of the galvano-cautery under cocaine anaesthesia. 
For the purpose of compressing the swelled soft tissues and cor- 
recting a deviation bougies are also used, made of zinc, tannin, or 
carbolic acid. Chromic acid and the galvano-cautery are my prefer- 
ences in the worst classes of cases; for instance, those of ozcena 
even in children, sometimes complicated with antrum disease, and 
very commonly complicated with or depending upon an excessive 
width of the posterior nares, like atrophic rhinitis, attributable to 
or connected with undue patency of the nasal orifice and of the naso- 
pharyngeal vault (Lennox Browne, Philad. Med. Jour., August 26. 
1899), do well under their influence. Others require the frequent 
use of stronger solutions of silver nitrate as a spray, or potassium 
hypermanganate solutions (1 to 1000 or 2000), or iodol or aristol 
insufflations, or a combination of a few of these remedies. For the 
purpose of cleaning the nasal cavities docile children may learn how 
to employ the nasal douche for copious irrigation. The douche ( foun- 
tain syringe) should never be raised more than a foot above the 
level of the nose, the fluid should be mild (salt water) and nearly 
of the temperature of the body, the head gently bent forward, the 
teeth parted, and respiration should not be interrupted by swallow- 
ing or coughing. If this happen, the tubing of the instrument should 
momentarily be compressed. Docile children may be taught to per- 
mit the flow of the fluid during inspiration only, the tube being com- 
pressed during expiration. The nozzle should be introduced horizon- 
tally into the narrower nostril. If sneezing comes on, it should take 



4 I2 DISEASES OF THE RESPIRATORY ORGANS 

place while the mouth is kept open, and blowing the nose should be 
done with one nostril open. 

Polypi, either congenital or acquired through chronic catarrh, 
though not frequent, will be met with in every medical practice. They 
are either soft and consist of mucous membrane, or harder and 
composed of dense connective tissue. Those with an admixture of 
sarcomatous tissue (not often round cells, more frequently spindle- 
shaped cells with copious stroma) are relatively rare. (Of primary 
sarcoma of the nose, Th. J. Harris {Phil. Monthly Med. Jour., June, 
1899) quotes one hundred and three cases. Of sixty-two cases whose 
ages were known, one was four, four were nine, two eleven, and two 
sixteen years of age.) The cold or galvano-cautery snare is required 
by those which have a rather bulky pedicle. Evulsion with a common 
polypus-forceps suffices for those which are distinctly pedunculated 
and for such as consist in the main of mucous membrane. A firm 
tampon is seldom required by excessive hemorrhage after evulsion. 
In most cases the bleeding ceases spontaneously; or a tampon of 
moderate size covered with powdered alum or tannin is demanded; 
or the cauterization of the stump with chromic acid, either dry or 
in a concentrated solution, by means of a camel's-hair brush or a 
probe covered with absorbent cotton. This application may be re- 
peated after a while to guard against a return. Or a watery anti- 
pyrin solution (from twenty to fifty per cent.), or a spray, or the 
application of the powder of adrenals, or their solution in water. 

Foreign bodies are often found in the nasal cavities of babies 
and older children. Paper balls, shoe-buttons, dry peas and beans, 
flies and bugs, cherry-stones, and beads are readily admitted. Their 
diagnosis is by no means always easy. Chronic catarrh, being their 
usual result, gives rise to the mistaken diagnosis of caries, syphilis, 
or tumor. The cases in which the presence of a foreign body causes 
delirium and convulsions, and may be taken for meningitis, are, fortu- 
nately, rare. In many, chloroform anaesthesia is required to ascertain 
the nature of the difficulty. The consecutive catarrh and ulceration 
require mild or disinfectant washes or injections. The ear-spoon, 
or Daviel's spoon, or a woman's hair-pin will generally suffice to 
dislodge the foreign body. While the child is firmly held, the oper- 
ator, standing a little behind and on one side of the patient, intro- 
duces the instrument from above downward, the cavity looking for- 
ward. In this way the foreign body is easily scooped out. When 
the symptoms are urgent (convulsions, high fever), an ala nasi has 
been incised to facilitate the required extraction. Dr. G. Bieser rec- 
ommends the following method {Ped., July 15, 1897). The child 



POLYPUS. FOREIGN BODIES. EPISTAXIS 



413 



is placed in the ordinary position for intubation, the assistant holding 
his hand firmly over the child's mouth. One end of a piece of rubber 
tubing is snugly inserted into the nostril opposite the one holding 
the foreign body, the other end is taken in the operator's mouth. The 
operator then blows suddenly and vigorously into the nostril and dis- 
lodges the foreign body. This method should not be employed, 
however, if it be too firmly impacted ; for in that case forcible insuffla- 
tion might injure the middle ear. In every case the mouth should 
be tightly closed. 

Epistaxis depends on the rupture of one or more blood-vessels, 
either large or small, normal or abnormal. The Schneiderian mem- 
brane is succulent and replete with blood; that is mainly so in the 
respiratory part about the lower and middle conchse, where the 
cavernous tissue is located, and the large veins are controlled by the 
spheno-palatine ganglion. A normal blood-vessel may bleed in con- 
sequence of a traumatic injury, or of an erosion by chronic catarrh, 
ulceration, diphtheria, or syphilis. Bleeding from the nose may point 
to the presence of a polypus, or be the indication of obstruction in 
distant parts of the circulation in the abdomen, the lungs (chronic 
pneumonia, emphysema), the thyroid body, or by cardiac disease. 
The compression of the abdominal viscera by enforced confinement 
in the school-ro'om, overheated and ill-ventilated at that, and con- 
secutive constipation are frequent causes of epistaxis. Blood-vessel 
walls become abnormally fragile in constitutional and infectious dis- 
eases, such as early chlorosis, tuberculosis, haemophilia, leucocythsemia, 
general amyloid degeneration, purpura, scurvy, and typhoid fever. 
Perhaps the most obstinate form of epistaxis, which is, fortunately, 
infrequent, is that which depends on the congenital incompetency 
of the heart combined with smallness of the large arteries, and results 
in the most serious cases of chlorosis. All these different causes of 
epistaxis suggest their own indications. The constitutional diseases 
resulting in local hemorrhage demand such management as has been 
indicated in other parts of this book. All of them may require local 
treatment besides. It is obvious that in every case of epistaxis the 
congestion of the nasal mucous membrane must be diminished if 
possible, and the formation of a clot should be facilitated. By raising 
the arms over the head, and by forced inspiration, the chest is ex- 
panded and a large amount of blood accommodated in it ; hot hand- 
and foot-baths have been resorted to for a similar purpose. Ice may 
be applied to the neck and throat, and pieces of ice introduced into 
the bleeding nostril. The local use of water (injection, washing) is 
not desirable, inasmuch as it is liable to prevent the coagulation of 



4 I4 DISEASES OF THE RESPIRATORY ORGANS 

the blood on the bleeding surface. Solutions of alum or tannin will 
answer a little better. The use of a tampon is often required to 
stop the loss of blood. The introduction of a wick of absorbent cot- 
ton or lint, by means of a pair of fine pincers, or, better, by loosely 
wrapping it round a smooth probe (whalebone or other), or of the 
same covered with alum or tannin, or soaked in a solution of iron 
perchloride or subsulphate ("haemostatic cotton"), combined with 
pressure from outside, or in an antipyrin solution ( from twenty to fifty 
per cent.), with or without tannin, will sometimes prove satisfactory. 
So will applications of adrenal powder in substance or in solution, 
or the local application of a thoroughly sterilized ten-per-cent. solu- 
tion of gelatin. In but a few will it be found necessary to close the 
whole cavity from either side by means of a tampon introduced 
through the mouth into the posterior nares, at the same time obstruct- 
ing the nose anteriorly. Bellocq's tube should not be used for that 
purpose, as it tears or cuts the tissue. An elastic catheter is easily 
carried through the nose and mouth, and the tampon attached to it. 
This procedure is not so annoying and irksome as it appears to be, 
because it is in few cases only that nose-bleeding is bilateral. In 
rebellious cases of older children the local cause should be looked 
for, — viz., an ulceration extending into blood-vessels. Ulcerations 
of the septum narium are not frequent in children, but they will 
occur. 

Chronic catarrh and ulceration of the nares must be treated accord- 
ing to the principles taught above, and the most frequent causes 
of epistaxis among children attended to according to their own indi- 
cations. Local ulcers may be reached with silver nitrate, the stick 
or a solution. I cannot impress too much the necessity of attending 
to the intestinal congestions and disorders of school-children. Con- 
stipation of a lifetime is often the result of the cramped position on 
an improper chair or bench, and of the inability to evacuate the bowels 
at the proper time. Children suffering from constipation, particu- 
larly those who are affected with what I have described as congenital 
constipation, may require a daily injection and may be benefited 
in urgent cases by an occasional (vegetable) purgative. This is 
sometimes all that is required to relieve their epistaxis. That many 
are relieved only when taken from school and allowed the free use 
of their limbs in the open air is self-evident. Another large class of 
nose-bleeders is that which originally suffered from chronic pneu- 
monia or chronic heart disease with general and persistent anaemia. 
Very many of these cases improve instantly under the sufficient use 
of digitalis, in efficient doses, and iron. 



NASAL ULCERATION. ACUTE LARYNGITIS 



415 



2. The Larynx. 

Acute laryngeal catarrh {acute laryngitis) is too common a dis- 
ease to justify a discussion here of its etiology or diagnosis. In re- 
gard to the latter, I refer to a single point only, — viz., that of the 
temperature, which is always elevated. An uncomplicated acute laryn- 
geal catarrh is always attended by fever, while an uncomplicated 
laryngeal diphtheria ("pseudo-membranous croup") is not so accom- 
panied. Dozens of years ago I brought out this fact, and a large 
experience has since confirmed that observation. The other symp- 
toms are unmistakable, from the different degrees of dyspnoea to 
those of hoarseness or aphonia, and the barking cough, which is 
quite characteristic and easily differentiated from that of other diseases 
of the respiratory apparatus, or from the reflex cough caused by 
foreign bodies in the naso-pharynx or in the ear. The treatment 
requires the most perfect rest. Talking must be prohibited, crying 
avoided, if possible. For that reason, if for no other, opiates are 
indicated ; partly to relieve the local irritation which produces cough, 
and partly to secure sleep for the purpose of equalizing circula- 
tion and resting the excited muscles. The temperature of the room 
ought to be equable (from 68° to 75 ° F.), the air moist. The 
latter eases the large windpipe and procures rest, while dry and 
cold air increase the irritation. Whatever beverages are given should 
be warm. A general warm bath, warm applications (hot water, 
poultices, cold applications which are permitted to become warm and 
are then changed), are both pleasant and beneficial. Plenty of water 
ought to be furnished, mild alkaline mineral water by preference. 
An infusion of ipecac with sodium bicarbonate, in small and frequent 
doses, will aid in liquefying a viscid mucous secretion. 

The worst form of acute catarrh of the larynx gives rise to 
attacks of intense dyspnoea ("croup"), which occur quite frequently 
in the night after the children have been asleep for some hours. 
The drying up of the pharyngeal mucus is very apt to give rise to 
both cough and dyspnoea, and therefore it is a good plan to wake 
the patient suffering from pharyngeal catarrh from time to time suffi- 
ciently to make him drink. Average moisture of the air may not be 
enough. Water ought to be kept boiling constantly, so as to fill the 
air of the room (or a tent, which ought to be spacious) with steam. 
Spraying the throat with cold water is useless compared with the 
effect of warm vapors. That leeches, which I used sometimes in bad 
cases of feverish and croupous catarrh forty years ago, ever resulted 
in any good I am not prepared to say; but a promptly adminis- 



4 l6 DISEASES OF THE RESPIRATORY ORGANS 

tered emetic (ipecac, zinc or copper sulphate, turpeth mineral, apo- 
morphine) has often relieved the spasmodic dyspnoea accompanying 
these (mostly nocturnal) attacks of " pseudo-croup." The effect 
of emetics, however, and their indispensability have often been exag- 
gerated. Usually they are less required for the relief of the babies 
than for tranquillizing the fears of the mother and allowing the 
family physician to stay in bed. 

Chronic laryngeal catarrh may develop out of a protracted acute 
catarrh, or the affection may be primarily mild, but result at an early 
period in the thickening of tissue. Even at the earliest age this process 
may be observed. One such case I saw with Dr. Hopkins, of Brook- 
lyn, in a newly-born baby, which got well after the daily administra- 
tion of a few grains of potassium iodide, continued' for several 
months. Constant warm applications, or cold ones which are per- 
mitted to become warm, will favor absorption. Cases which are 
complicated with, or perhaps dependent upon, a chronic pharyngeal 
catarrh are often favorably influenced by the use of tincture of pim- 
pinella saxifraga, half a drachm or a drachm of which may be taken 
daily, in ten or twelve doses, in a solution of potassium chlorate, 
in such a way that the dose of the latter be a cautious one and the 
dilution (in water) of the tincture be not excessive. This drug has 
long been " obsolete," but deserves to be reappointed to its former 
place in practice. The majority of such cases will do well when 
treated with solutions of sodium bicarbonate or potassium iodide, 
also of ammonium chloride in daily doses of from eight to thirty 
grains (0.5 to 2.0). 

Diphtheritic Laryngitis, Pseudo-Membranous Croup. — It is not 
necessary to discuss here pathological questions, or to reassert the his- 
tological identity of diphtheria and " croup." When pharyngeal diph- 
theria has reached the larynx in its descent, or bronchial diphtheria 
resulted, in its ascent, in sudden laryngeal stenosis, the usual anti- 
diphtheritic treatment avails but little. That neither general nor 
local depletion has any effect, except that of hopelessly reducing 
the patient's strength, has long been recognized ; also, that vesica- 
tories add a new diphtheritic membrane on the surface to those on 
the mucous membranes. Emetics are of no use unless a peculiar flap- 
ping sound betrays the presence of half-detached membrane in the 
air-passages. In such a case they are apt to save life. At all events, 
I have never been so fortunate as to observe the universally beneficent 
effect which has been attributed to their frequent administration in an 
average case. Massage of the larynx has been recommended by 
Bela Weiss. I cannot say that the few cases in which I advised the 



LARYNGEAL CATARRH AND DIPHTHERIA 417 

procedure were successful; it may be that the constant repetition of 
the advice to use mercurial or other ointments over the larynx is based 
on the observation of an occasional good effect of the friction (" mas- 
sage") attending their employment. Locally, lactic acid, in more or 
less saturated solutions, has been eulogized as a solvent of the mem- 
branes in the larynx, when often applied either by brush or spray. 
Most of the cases in which I have seen it used were not successful, 
but this untoward result is, unfortunately, not exceptional. I have 
seen, or believe I have seen, papayotin ( 1 ) dissolve membrane when 
applied in a mixture of glycerin and water (aa 2). Particularly 
would that occur in pharyngeal diphtheria slowly descending. Lime- 
water is still used as a spray and has its admirers. Lime slaked in 
a small room or under a tent is decidedly more effective, for during 
that process a large quantity of lime is carried up and inhaled; at 
the same time the softening and solvent effect of the steam is obtained. 
The latter is not always as beneficent as it appears. In many the 
application, externally, of cold water or ice-bags to the neck is vastly 
preferable. But in most cases of anaemic and highly nervous chil- 
dren the latter are not tolerated. Constant inhalations of turpen- 
tine, or eucalyptol, or (in older children) carbolic acid, from a kettle 
containing boiling water, have impressed me as beneficial in a large 
number of cases. Inhalations, in a small room or under a tent, of 
calomel, which is sublimated in doses of eight or ten grains (0.5), 
every hour or at longer intervals, are certainly effective. 

The patient remains in bed as much as possible, and may continue 
such expectorants as he perhaps took for previous catarrhal symp- 
toms ; may also take diaphoretics and warm beverages, and an occa- 
sional opiate for that indication and to procure some rest. The con- 
tinuation of potassium chlorate when the invasion of the larynx is 
complete is rather superfluous. Antipyretics are out of the question 
unless there is a very high temperature depending on a complication 
(general diphtheria, pulmonary inflammations). Pilocarpine injures 
by debilitating the patient ; the cases which are really benefited by it 
are excessively rare. Mercurials have resulted in more actual re- 
coveries than any other internal treatment. The cyanide and iodide 
have been recommended. For twenty-five years I have employed 
the bichloride in doses of a milligramme (one-sixtieth grain) or 
more once every hour. The smallest babies easily take one-fourth 
or one-third of a grain daily for days in succession. Almost never 
will a stomatitis follow, and no gastric or intestinal irritation, pro- 
vided the dilution be in the proportion of at least one in eight or 
twelve thousand. An occasional slight diarrhoea may require the 

27 



4 i8 DISEASES OF THE RESPIRATORY ORGANS 

addition of a few drops of camphorated tincture of opium. I will 
repeat a former statement, that never have I seen cases of croup 
getting well in such numbers, either without or with tracheotomy 
or intubation, as with mercurial treatment. When this treatment 
proves unsuccessful, intubation or tracheotomy must be resorted to. A 
small, frequent, and intermittent pulse, aphonia, cyanosis, and marked 
retraction, with every inspiration, of the supraclavicular fossae and 
the epigastrium are the indications for the operative procedure. I 
shall not here be tempted to defend the two operations; I shall not 
even stoop to discuss the criminality of allowing a child to suffo- 
cate without resorting to mechanical relief, or to compare the two 
operations with each other. I can only say that for years I have 
not seen a case in which intubation would not take the place of trache- 
otomy, and have therefore not performed the latter. Intubation has 
come to stay; it is not one of the many temporary devices which 
have been brought out to be instantly forgotten. In most cases it 
takes the place of tracheotomy; in none does it make it impossible 
when, in the opinion of the operator, required. The latter operation 
may be preferred or become necessary for the purpose of getting at 
the trachea and bronchi for the mechanical removal of membrane and 
for other local treatment, rare though the cases be in which such pro- 
cedures are attended by success. It is probable that the many sec- 
ondary tracheotomies which are still performed by some in Europe, 
when intubation is alleged to be insufficient, will not be considered 
requisite in the future. 

In the consideration of pseudo-membranous laryngitis it should 
not be overlooked that in the vast majority of cases the Klebs-Loffler 
bacillus is found; and that all of these are, therefore, fit subjects 
for the use of the diphtheria antitoxin. Since its introduction both 
general and local (laryngeal) diphtheria have been greatly benefited. 
In its Washington meeting of May, 1897, the American Pediatric 
Society received the " report of its committee on the collective inves- 
tigation of the antitoxin treatment of laryngeal diphtheria in pri- 
vate practice." Its salient points are as follows. The number of 
cases reported during the eleven months ending April 1, 1897, was 
1704, mortality 21.12 per cent. The cases occurred in the practice 
of 422 physicians in the United States and Canada. Operations 
employed : intubation in 637 cases, mortality 26 per cent. ; trache- 
otomy in 20 cases, mortality 45 per cent. ; intubation and tracheotomy 
in 11 cases, mortality 63.63 per cent. Number of States represented 
2.2, besides the District of Columbia and Canada. Non-operative cases 
1036, mortality 17.18 per cent.; operated cases 668, mortality 27.24 



DIPHTHERITIC LARYNGITIS. STENOSIS 419 

per cent. Two facts may be recalled in connection with these state- 
ments. First, that before the use of antitoxin 90 per cent, of laryn- 
geal diphtheria required operation; under the antitoxin, however, 
39.21 per cent. Second, that the percentage figures have been re- 
versed ; formerly 27 per cent, represented the recoveries, now, under 
antitoxin, the mortality. The committee expects still better results 
when antitoxin is administered earlier and in larger doses, and rec- 
ommends that all cases of laryngeal diphtheria, the patient being 
two years or over, should receive as follows : two thousand units 
at the earliest possible moment, two thousand units after twelve or 
eighteen hours unless there be an improvement, and the same dose 
twenty-four hours after the second dose if there be still no improve- 
ment. Patients under two years should receive one thousand or 
fifteen hundred units. 

Dr. Dillon Brown's personal experience being unusually large 
and carefully recorded, I add without comment the following figures 
reported by him. He divided his cases into three classes: previous 
to November, 1890; from November, 1890, to September, 1894 (calo- 
mel sublimation period) ; from September, 1894, to April 1, 1897 
(antitoxin period). Of 442 cases of intubation without calomel sub- 
limations and without antitoxin, 27.3 per cent, recovered; of 295 
cases of intubation with calomel sublimations, 41.6 per cent.; of 
69 cases of intubation with antitoxin, 67.8 per cent, recovered. With- 
out sublimations, 10.1 per cent.; with sublimations, 13.2 per cent.; 
with antitoxin, 23.3 per cent, recovered. During the first year with 
antitoxin there were recoveries after operation in 38.4; during the 
second year, 62.9; during the third, 94.7 per cent. The apparently 
bad results during the first year were probably due to two causes: 
inferior antitoxic serums and insufficient doses. 

The doses have been considerably increased of late. There can 
be no conscientious objection so long as mishaps after the use of 
antitoxin do not result. Altogether, the American results are con- 
firmed in Europe, where O'Dwyer's intubation has conquered the 
field. Von Bokay, Widerhofer, von Ranke, Ganghofner, Heubner, 
Baginsky, lately Trumpp and Siegert ; in fact, everybody favors the 
combination of antitoxin and intubation in pseudo-membranous laryn- 
gitis. 

Stenosis of the larynx and trachea, after ulceration and cicatriza- 
tion by diphtheria, by spontaneous gangrene, or by pressure caused 
by tracheotomy or intubation tube, may cause great difficulty. 
Among the recommendations given for such occurrences are: in- 
tubation with or without the division of the stenosis; excision of 



4 20 DISEASES OF THE RESPIRATORY ORGANS 

the obliterated and contracted part, and suture; plastic operation 
with the aid of a skin-periosteum-bone-flap or a skin-cartilage-flap 
taken from the thyroid cartilage ; excision of the cicatrix and trans- 
plantation (Thiersch) of a skin-flap to cover the artificial defect of 
the mucous membrane. 

Neurotic affections of the larynx of infants (and older children) are 
quite frequent, particularly spasm of the glottis, under the influence 
of the inferior laryngeal nerve, which controls both the contractors 
and the dilators of the glottis. The treatment is directed by its mani- 
fold causes. Indigestion, both chronic and acute, is a frequent cause 
and should be relieved; particularly in neuropathic families the diet 
and hygiene of the infant are of the utmost importance. Fresh air, 
cautious exposure to cool or cold water, and early addition of liquid 
animal food to mother's milk or to the artificial feeding are of im- 
portance. Rhachitis, being the most frequent cause of laryngismus 
stridulus (p. 132), requires early attention; digestive disorders must 
be corrected, and the general irritability relieved by bromides or cam- 
phor. Monobromated camphor may be given for weeks in daily doses 
of from one to three grains (0.05 to 0.2). Emotional disturbances, 
which will affect neurotic children at an early age, should be avoided. 
A screaming spell and fright will act as proximate causes. The 
attacks (some beginning with apncea, mainly those of laryngismus 
stridulus) must be watched, the baby taken up so as to ease the 
larynx, the head raised, the tongue (if aspirated and doubled up) 
drawn forward, the throat tickled, water dashed into the face, and 
chloroform inhaled if the local spasm be followed by a general con- 
vulsion. The influence of the thymus gland was discussed on page 
146. Spasm of the glottis is, or may be, one of the constituent symp- 
toms of stammering (p. 308). 

Paralysis of the glottis is not so frequent; in the infant quite 
rare, and very rarely congenital. Diphtheria, hysteria, and cerebral 
diseases, also whooping-cough, which should be relieved as much 
as possible, may give rise to unilateral or bilateral paralysis, anaemia 
may create a predisposition, glandular swellings prove a proximate 
cause. Hysterical paralysis with aphonia appears quite suddenly, 
sometimes as the only symptom of hysteria, sometimes in combina- 
tion with others. One of them is anaesthesia and absence of reflex 
of the fauces. Complete paralysis depending on that of both pos- 
terior muscles, which contract the glottis, produces a very severe 
dyspnoea, which is relieved during expiration but cannot be tolerated 
long. Intubation or tracheotomy may be demanded for immediate 
aid. Otherwise, attention to the predisposing causes, reduction or 



NERVOUS AFFECTIONS OF THE LARYNX. NEOPLASMS 421 

removal of glands, and mainly the systematic application of the inter- 
rupted current through the breadth of the larynx will offer relief and 
gradual, sometimes rapid, recovery. 

Neoplasms of the infant's or child's larynx are by no means rare. 
Many of them are congenital ; mostly so the numerous papillomata. 
Fibromata and enchondromata are also met with, and epithelioma 
has been observed. Sometimes they develop their first symptoms after 
an incidental inflammatory affection, or after an acute exanthema. 
Laryngoscopy is very difficult in the young. It can rarely be done 
without general anaesthesia and drawing the tongue out. I saw pulse 
and respiration stopped and tracheotomy necessitated to save the 
child's life. (Alcohol applications have been recommended for their 
removal.) The rules for their removal are about the same as in 
the adult, only the latter are more amenable to operations through 
the mouth. Indeed, none but older children can be thus treated. 
A. Rosenberg collected two hundred and thirty-one cases of laryngeal 
papillomata in children {Arch. Laryngol., vol. v.) . Laryngotomy gave 
thirty-seven per cent, recoveries. In 38.5 per cent, there occurred re- 
lapses. In the practice of a single surgeon there were seventeen opera- 
tions for rapid recurrences within three years. Mere tracheotomy was 
performed in thirty-four cases; four recovered spontaneously after- 
wards. That is the plan followed by G. Hunter Mackenzie {Br. Med. 
Jour., May 20, 1899), wno asserts that when tracheotomy alone is 
performed, papillomata will disappear within a few months or a year. 
Of Rosenberg's cases, endolaryngeal treatment after tracheotomy 
resulted in a permanent cure in twelve, temporary improvement in one, 
and relapses in three cases. Exclusive endolaryngeal treatment gave 
a complete cure in fifty per cent, of children under four years, seventy 
per cent, between four and eight, and fifty per cent, of eight years and 
older. According to these figures, endolaryngeal treatment is prefer- 
able unless there be a dangerous degree of dyspnoea, which can be 
treated by intubation; tracheotomy with subsequent endolaryngeal 
treatment will be the next choice, and laryngotomy will be reserved 
for very serious and unusually urgent cases. Still, it appears that 
the latter will be preferred by all who do not claim great specialistic 
skill and have no hospital at their disposal. Laryngotomy is per- 
formed after (or without) tracheotomy, according to surgical rules, 
exactly as for the extraction of foreign bodies. There is one danger 
more urgent in infants and older children than in adults, — that is, 
hemorrhage, slight or copious. Blood flowing down into the narrow 
air-passages, even in small quantities, is liable to result in lobular pneu- 
monias of a dangerous character. The operation should, therefore, not 



422 DISEASES OF THE RESPIRATORY ORGANS 

be performed without a thermo-cautery or electro-cautery ready for 
immediate use. Foreign bodies in the larynx, more frequent in the 
young, though with less mortality than in the old, but more fatal than 
even those in the trachea and bronchi, should be removed through 
the mouth, if possible ; if not, by laryngotomy. Laryngoscopy should 
precede it, when possible. In order to facilitate the exit of a foreign 
body from the trachea or the bronchi, tracheotomy is demanded, after 
which it is best not to introduce a tube, except temporarily. The 
trachea may then be sewed to the integuments, or may be kept open 
by hooks joined by an elastic band, according to A. Caille. 

Congenital stricture of either the larynx or the trachea (rare, 
fortunately) may be mistaken for laryngeal tumor. 

3. The Bronchi. 
Bronchial catarrh (bronchitis) , in all its localizations, from the 
windpipes of large size down to the capillaries, requires an equable 
temperature of about 70 ° F., moist air, and rest in bed, though there 
may be no fever except a slight one towards evening. Plenty of 
water, — no ice, — preferably alkaline mineral waters, should be given ; 
older children may be prevailed upon to take gum-arabic water, 
flaxseed tea, or other glutinous decoctions which relieve the accom- 
panying pharyngeal irritation. Mitigated mustard-plasters (mus- 
tard 1, flour 4 or 8) or embrocations of turpentine are used to advan- 
tage. Underclothing must be changed when moist with perspiration. 
A cotton-batting wrapper round the chest (the sheet spread out 
and two arm-holes cut into it) acts favorably both by keeping up a 
uniform temperature and by gently irritating the surface. As a rule, 
it acts better than warm poultices, which are liable to moisten the 
clothing and bedding, and thus add discomfort and the danger of 
a new attack. Where, however, the surface is dry, they may be 
applied, or, better still in most cases, a sheet of one or two thicknesses 
well wrung out of cool water, wrapped round the chest and changed 
every hour or half-hour after it has got hot. Sodium bicarbonate 
from ten to fifty grains (0.6 to 3.0) daily, according to age, and 
an equivalent of a grain of ipecac distributed over the day, or (and) 
from ten to twenty grains (0.6 to 1.5) of ammonium chloride with 
equal parts of extract of licorice daily, divided into many doses 
during a day when expectoration is viscid and requires liquefying, 
will answer in most cases. Apomorphine one-one-hundred-and-twen- 
tieth grain (0.0005) every two or three hours will act as an expec- 
torant, so will terpin hydrate in frequent doses of from one-quarter 
to one-half grain (0.015 to 0.03), particularly in chronic catarrh. 



BRONCHITIS 423 

Complication with asthma and insufficient expectoration is benefited 
by potassium iodide in daily doses of four or fifteen grains (0.25 
or 1.0), refracted. Insufficient expectoration with general debility 
demands ammonium carbonate (gr. % to 1=0.015 to 0.06), in 
anise-seed tea or in milk, every half-hour or at longer intervals, 
aq. camphorse (one-half to one teaspoonful) often, or camphor (gr. 
y e to 1 = 0.01 to 0.06) every half-hour to every two hours in 
diluted mucilage. The German preparation of liquor ammon. ani- 
satus has been introduced into the Formulary of the American Phar- 
maceutical Association; from two to six drops may be taken every 
hour or two hours. Accumulation of mucus in the bronchial tubes, 
with inability to expectorate and danger of suffocation, may demand 
an emetic, and asphyxia cold affusion and raising the infant and carry- 
ing him about : frequent change of position is advisable in every severe 
case. When, in bad cases of capillary bronchitis, cyanosis is on the 
increase, and the voice has not been heard for some time, it is abso- 
lutely necessary to make the baby cry. Slapping with a wet hand- 
kerchief, swinging, or closing the nares for a few moments, and 
all the means recommended for the asphyxia of the newly-born, are 
demanded. The interrupted electric current may be used with the 
rules and restrictions recommended above (p. 84). Cough, when 
irritating and harassing, requires narcotics. Small doses of an opiate 
at regular intervals, or (and) a larger one at bedtime, or repeated 
doses of extr. hyoscyami (grs. 1 to 1J/2 = 0.06 to 0.1 altogether 
through the day), and an opiate for the night, act very beneficially. 

The chronic form of bronchial catarrh demands similar medi- 
cation. Preventive measures are the habitual use of cool or cold 
water and the treatment of such constitutional disorders — for in- 
stance, rhachitis — as are known to create a predisposition. Plenty 
of water, or alkaline water, will dilute expectoration. When this is 
very copious and difficult, and the cough most annoying in the morn- 
ing, the patient should be kept lying down for several hours, with 
the trunk raised. Terpin hydrate and terebene, ten or twenty drops 
daily, will act well. Ammonium chloride may be evaporated on a 
hot stove or tin, enough to penetrate the whole room (no tent re- 
quired), and inhaled. Turpentine inhaled with steam or spread on 
sponges or towels is also useful. The pneumatic treatment (inhala- 
tion of compressed air) has been recommended again by Biedert 
and Quimby; it finds its principal indications in atelectasis and peri- 
bronchitis. The frequent complication with pharyngeal catarrh de- 
mands the local treatment of the fauces; a mild solution of silver 
nitrate (1 to 500) may be used as a spray once every day or every 



424 DISEASES OF THE RESPIRATORY ORGANS 

two days. When tuberculization is feared, the protracted use of 
cod-liver oil, guaiacol several times daily in two- or four-drop doses, 
or creosote, or their carbonates, which are taken so much more readily, 
together with a change of climate, preferably moderate altitudes, 
are indicated. 

Fibrinous bronchitis is by no means so rare as it was formerly 
reputed to be. Indeed, during epidemics of diphtheria it is not un- 
common. Still, the pseudo-membranes found in the bronchi are not 
always of the same nature. While some are diphtheritic, others con- 
sist of dry and coagulated mucus resembling the membranes of 
" enteritis membranosa." In accordance with this difference of the 
prevailing condition, a case may last days or months. Antipyretics 
are still less indicated than in the common forms of bronchitis. Mer- 
curial treatment like that required in diphtheritic laryngitis of every 
variety (p. 417) is the most reliable internal remedy. Inhalations 
of steam, frequently repeated or kept up constantly in urgent cases, 
inhalations of turpentine with or without steam, of ammonium chlo- 
ride, often repeated, and fumigations through one or two days of 
from five to fifteen grains (0.3 to 1.0) of calomel (when dyspnoea 
is urgent, every hour or every few hours, under a tent) will act well. 
The internal use of potassium iodide in daily doses of from ten to 
fifty (0.6 to 3.0) grains, and, in cases of undoubted bacillary diph- 
theria (p. 245), antitoxin are indicated and useful. 

Bronchial catarrh, croup, and some forms of pneumonia are proxi- 
mate causes of a collapse of pulmonary tissue (atelectasis) , the con- 
genital and postnatal varieties of which have been treated of before 
(p. 86). The predisposing causes are general atrophy with its mus- 
cular debility, and rhachitis through its narrowing the thorax. In 
this condition, replete as it is with imminent danger, the baby must 
be carried about, the posture in bed must be changed frequently, 
he must be made to cry, electricity should be used, and, besides 
an occasional emetic, stimulants, such as alcohol, camphor, am- 
monium carbonate, and musk, should be employed frequently and 
copiously. 

Bronchiectasis may have one of several causes. The bronchial 
wall may be feebly developed at birth; it may become weakened by 
the degenerative processes of an acute or chronic bronchitis; or it 
is acquired by the traction of cicatrizing pulmonary tissue, resulting 
from the effects of a protracted interstitial peribronchitis ("pneu- 
monia"). Arsenic and phosphorus treatment is indicated when the 
former conditions, iodides when the latter can be diagnosticated. 

The nature and symptoms of asthma do not differ from those 



ASTHMA. COUGH 425 

of the same affection in adults; nor does the treatment. It is a 
spasm of the circular muscle of the bronchi (not the diaphragm). 
When a catarrh (bronchitis) precedes or follows it, the feebler 
longitudinal fibres of the muscular layer lose in strength compared 
with the circular, and prolong the attack. During the attack proper 
there is very little expectoration, the bronchioles being filled with 
lymph exudate and large cells and the Leyden crystals. Its neurotic 
character is illustrated by those cases which are accompanied by urti- 
caria (internal urticaria? A. Packard). Swelling of the medias- 
tinal glands, adenoids, hypertrophy of the tonsils, flatulency which 
impedes the free movements of the diaphragm (" asthma dyspep- 
ticum"), peribronchitis, emphysema, which is by no means rare, and 
nasal reflexes are the main causes, and should be attended to. In 
the latter class of cases brushing the mucous membranes of the 
nose and pharynx with a cocaine solution of from two to ten per 
cent., or the use of cocaine spray, may, in appropriate cases, relieve 
an attack; the cauterization (actual or chromic acid) of the hyper- 
trophied tissue and the removal of a polypus may occasionally be 
the only things required for an actual cure. Unfortunately, this 
class of cases is not so numerous as it was believed to be a number 
of years ago. Those depending on peribronchitis and emphysema are 
more frequent. In them the protracted use of three daily doses of 
from two to five grains (0.125 to °-3) °f potassium iodide, together 
with a sufficient bedtime dose of chloral or of an opiate to meet the 
night attack, will have favorable results. Tincture of lobelia, two 
or three drachms (eight or twelve cubic centimetres), fluid extract 
of quebracho or of grindelia, one or two drachms (four or eight cubic 
centimetres) daily, will often have a beneficial effect in distressing 
dyspnoea. The inhalation of stramonium, of potassium nitrate paper, 
or of pyridin vapors is often resorted to ; unfortunately, with so little 
permanent result as to give any number of proprietary medicines 
and nostrums a large field of activity. The treatment of enlargement 
of mediastinal glands, of tonsils, and of flatulency has been discussed 
in other chapters. 

The periodic night-cough, described as a special variety in some 
of the books, is either a mild attack of asthma or is pharyngeal or 
tubercular; most pharyngeal coughs, however, are met with in the 
morning, after waking up. These nocturnal attacks may be obviated 
by a drink of alkaline water at bedtime, to be repeated at every 
waking up, by a dose of a bromide, or of chloral, or of an opiate 
at bedtime, and by attention to indigestion and constipation. Qui- 
nine is useless. A reflex cough may depend on changes or a foreign 



426 DISEASES OF THE RESPIRATORY ORGANS 

body in the external ear, the septum or the conchse of the nose, or on 
a neurosis of the stomach. A careful examination with otherwise 
negative results will direct attention to these localities and indicate 
the treatment. 

4. The Lungs. 

Pneumonia. — There are three anatomical varieties of pneumonia 
in infancy and childhood: the catarrhal or lobular, the fibrinous or 
lobar, and the interstitial. Nearly two-thirds of the cases belong to 
the first, one-third to the second, and a limited number to the third 
class. Not one of them, however, is always found pure and uncom- 
plicated. Indeed, complications of the lobular with the lobar, of 
either of them with the interstitial, and possibly of each of the three 
with pleurisy are quite numerous. The lobular form is almost always, 
the lobar quite frequently, preceded by bronchial catarrh, which has 
its well-understood sources in previous attacks, in exposure, sudden 
changes of temperature, local irritation by foreign bodies, rhachitical 
or tubercular mediastinal and bronchial glands, diphtheria, measles, 
influenza, typhoid fever, whooping-cough, etc. Thus, the preventive 
treatment of pneumonia has its positive and distinct indications. Nasal 
catarrh is never so slight as not, possibly, to endanger the lungs. Rha- 
chitis, glandular tuberculosis, measles, and whooping-cough must not 
be let alone to find their slow road to their legitimate termination for 
better or for worse. Every child, while well, should be armed against 
the results of exposure by regular invigorating ablutions and fric- 
tions with cold water, and when exposure has taken place and the con- 
sequent fever made its appearance, a warm bath, ammonium acetate, 
camphorated tincture of opium, tincture of aconite, hot drinks, sodium 
salicylate, or another one of the antipyretics and diaphoretics, with 
uniform temperature and rest in bed, may be the means of preventing 
pneumonia. 

The treatment of pneumonia is not yet much influenced by modern 
views on etiology. The attempts at procuring immunity in animals 
by the blood-serum of pneumonic patients, thus establishing a serum- 
therapy, may prove more successful when more is known. The 
large number of microbes which are found in pneumonia — pneumo- 
coccus, diplococcus lanceolatus, streptococcus, staphylococcus, and 
others, which are found as well in other parts of the body and in 
other processes — do not yet justify the removal of pneumonia from 
among pulmonary diseases and its exclusive classification among infec- 
tious fevers. The assertion that it is only a process of germ-culture 
in which the air-cells act as culture-tubes and the exudation as a 
culture-medium, while the nutrient circulation maintains the integrity 



PNEUMONIA 427 

of structure without taking an essential part in the pneumonic 
process, has been ably defended by A. H. Smith, who explains the 
pneumonic crisis by the death of the pneumococcus and the formation 
of an antitoxin when the culture-medium is exhausted, and finally 
by the fatal influence on the pneumococcus due to pneumic acid 
(which normally binds carbonic acid in the lungs), which meets no 
longer with carbonic acid. 

Both the infectious and the contagious character of pneumonia 
were observed by Sir Hermann Weber in 1869. He describes (Fest- 
schrift, 1900) cases of a " pneumonic fever as an infectious fever, 
the prominent symptom of which is a lobar pneumonia." His cases 
ran, after an incubation of from eleven to thirteen days, an acute course 
of four to six days, were located in the lower lobe, very contagious, 
and exhibited a rapid decline. One developed afterwards great weak- 
ness of the heart, one neuritis, and one a peculiar delirium such as 
he has frequently met with in the rapid decline of febrile diseases. 

On the other hand, lungs of children who did not die of pneu- 
monia, also those of recently killed domestic animals (Diirck in 
Deutsche Arch. klin. Med., 1897, vol. lviii.), contained the diplococcus 
pneumoniae and the mixture of bacteria met with in pneumonia. Pure 
cultures of bacteria blown into healthy lungs gave Diirck no pneu- 
monia, irritant dust did; so did cultures and dust mixed. Here, as 
almost everywhere in bacteric etiology, it is not the presence of ever 
so many highly virulent microbes, but their fixation and their ability 
to generate toxins, which deserve credit for morbid tissue changes. 

Acute lobular pneumonia is less a systemic disease than is the 
lobar form; its direct and immediate influence on the nervous and 
muscular, inclusive of the cardiac, systems is less marked; it is 
not so frequently complicated with pleurisy. Thus, there is less 
danger at first in lobular pneumonia ; there is more at a later period, 
because its duration is liable to be so long as to make the prognosis 
uncertain. The danger may come from the heart, but it mainly lies 
in suffocation, which depends less on the extent of inflammatory 
exudation than on collateral congestion and cedema. 

Interstitial pneumonia runs the most protracted course. Fever 
is liable to be high and prolonged over weeks and months ; recovery 
is rarely complete, induration and retraction of the pulmonary tissue, 
with bronchiectasis, being quite common. Bronchitis is often early 
and extensive, mainly when there is pleuritis also, and liable to become 
chronic. 

Thus, it becomes evident that no uniform course of treatment 
can be dictated either for all forms of pneumonia or for all cases. 



428 DISEASES OF THE RESPIRATORY ORGANS 

The former are several, the latter are individual. After all, the 
patient is to be treated, and not the Greek name of his disease. Still, 
there are certain rules which ought to be enforced in every case. 

Insist upon absolute rest of body and mind, exclude visitors, light, 
and noise. 

Keep the temperature of the room between 68° and 72 ° F. and 
the air moderately moist. 

Let the patient select his own position. 

Isolate a lobar case. 

Give liquid food and plenty of water, or lemonade, or hydro- 
chloric acid and water. 

Relieve the circulation from accessory incumbrances; a dose of 
calomel will facilitate the action of the diaphragm by emptying the 
bowels and relieving flatulency, and will diminish the tension of the 
arteries. 

The main dangers in acute pneumonia are: high temperature, 
heart-failure, and suffocation, which may result from the condition 
either of the lungs, or of the right heart (the left not being at fault 
so often as it is in the adult), or of both; also complications like that 
with nephritis, which is either a coincident or the result of toxic 
(pneumococcic?) infection. 

Which degrees of temperature may be allowed to last and which 
are to be interfered with? Is it 103 , 104 , or 105 F. ? It is well 
understood that persistent high temperatures disintegrate tissue, 
but this effect is not equally observed in all cases. Many a child 
bears 104 quite easily, while others succumb to 103 °. Moreover, 
a temperature which is badly borne the first day or two appears to 
be an indifferent matter afterwards. Thus, an antipyretic treatment 
may be indicated at first and be no longer required later, particularly 
in those cases which exhibit a decided morning remission; for it 
is mainly a persistent height of temperature that is injurious, not 
its occasional, though regular, rise. That is why, for instance, re- 
lapsing fever, with its enormous temperatures but complete and long 
intermissions, has only a small mortality. 

The custom of depressing temperatures in all cases which exhibit 
103 ° F., or thereabouts, is bad; it is not the temperature that 
is, by itself, injurious, but the absence or insufficiency of resistance that 
the tissues offer to its action. To lower temperature we have a num- 
ber of remedies. The latest additions to our antipyretic treasures are 
very well known and too universally employed. Phenacetin, antipyrin, 
etc., have more frequently lowered temperatures than they have saved 
lives. Their doses, uses, and dangers are well understood by all prac- 



PNEUMONIA 



429 



titioners. Whenever they are found incompetent, their combination 
with quinine has proved more effective. The latter, by itself, is, 
however, no longer the sine qua non which it was formerly believed 
to be. In all cases with marked remission it acts well, but it should 
be given only during the remission. From half a gramme to a 
gramme (eight to fifteen grains) may be thus employed. It may 
be used internally or hypodermically. Now and then injections 
into the rectum, or suppositories, are required or advisable when 
the stomach cannot be relied upon. The preparation to be used in 
the rectum must be one of those which are most soluble: the bisul- 
phate, muriate, bromide, or carbamide. No acid should enter into 
the solution; large quantities of glycerin are objectionable. The 
rectal dose should be at least fifty per cent, larger than that employed 
internally (p. 6j). 

The best antipyretic is cold (p. 57). Its use has been praised 
and condemned, as everything deserves to be that is employed 
either properly or thoughtlessly. Most cases will do quite well 
with sponging, or with friction by means of wet and cold towels. 
The latter plan acts both as a refrigerant and a stimulant. Cold 
bathing was once eulogized immensely, then rejected and warm 
bathing substituted. The rationale of cold bathing is the cooling 
of the surface (that is, of fourteen square feet or more in the adult; 
more than proportionately that in the young) with its immense 
surface circulation. So long as this circulation continues active, new 
blood will come to the surface every moment, and the whole body 
is thereby cooled. When it is no longer active, the heart weak, and 
the extremities cold, cold bathing is dangerous. The rule I have 
always followed is this : no cold bath for cold extremities ; no more 
cold bathing when once, after it, the extremities remain cold or cool. 
In these cases after a cold bath the surface becomes colder than 
before, it is true; the interior, however, warmer than it was. I 
reported the case of a little child, thirty years ago, that was the 
first to teach me that lesson. A few cold baths had reduced his 
temperature and his tendency to convulsions. Then another seemed 
to be indicated. It appeared to render the required service, but the 
baby became convulsed. The temperature in the rectum had risen 
from 104^° to 106 F. A hot bath, instantly given, restored the 
external circulation, and ten minutes afterwards the rectal temper- 
ature was below 102 °. 

A great promoter of circulation, and thereby of radiation from 
the skin, is surface warmth, and particularly warm extremities. 
Warming-pans ought always to be applied to the feet and legs when 



430 DISEASES OF THE RESPIRATORY ORGANS 

cold is to be employed on the rest of the body. In place of cold 
bathing, I have mostly employed cold packing from the chest down 
to the thighs, the arms usually outside the pack. Nothing is easier 
than to wrap a baby up in a single wet towel, which is covered by 
a small blanket; in an urgent case it should be replaced by another 
one (spread out beforehand) every two or five minutes. From 
twenty to forty minutes' packing will reduce the temperature from 
io6° to ioi° F., and below. In many instances the rapidly falling 
temperature demands artificial warming immediately afterwards. 
When the frequent changing of the pack is undesirable, the cloth 
may be allowed to remain, and is frequently cooled by rubbing a 
piece of ice over the whole surface. If water collect under the patient, 
it can easily be absorbed by towels or sponges. A temperature of 
108 in a baby of four months, suffering from pneumonia, was re- 
duced to 104 in twenty-five minutes; after that it sank rapidly to 
943/2 ° F., and artificial warming of the surface was required. 

From what has been said it is evident that very feeble and anaemic 
babies do not tolerate cold, though their temperatures be ever so high ; 
in such cases a warm bath, or tepid packs either with water or alco- 
hol and water, or a warm bath gradually and gently cooled down 
while the little body is constantly being rubbed, should take the place 
of the cold pack ; or cold applications to a part, perhaps the anterior 
aspect of the chest, are found to suffice. They both reduce tempera- 
ture and relieve local pain. In many cases a light ice-bag over the 
heart acts both as a refrigerant and a stimulus to the organ at the 
same time. 

The acceptance of these views I urgently recommend to those 
to whom they are in part new. Before and after 1870, when I recom- 
mended {New York Medical Record) cold water in typhoid fever, 
scarlatina, variola, ophthalmia, diphtheritic conjunctivitis, diphtheria, 
lobar and other pneumonia, heart disease, local inflammations, phleg- 
mon, synovitis, and peritonitis, I had ample opportunities to test what 
I am here advocating. Those who want to inform themselves thor- 
oughly on matters connected with this subject I refer to Dr. Simon 
Baruch's well-known book, and other writings. 

The heart furnishes urgent indications for treatment in many 
cases of pneumonia. When in a healthy condition, its innervation 
and force are not easily disturbed ; still, every pulmonary disease 
taxes its powers. Lobar pneumonia requires cardiac stimulation at 
an earlier period than the lobular kind. There is none, however, 
that does not demand it at some time or other. That being the case. 
I earnestly advise not to wait, for heart-failure is more easily pre- 



PNEUMONIA. ALCOHOL. DIGITALIS 



431 



vented than cured. Be our treatment ever so expectant, it must not 
be indolent and indifferent. In order to correct the faulty pulmonary 
circulation the heart should be stimulated at an early period; but 
how? 

Alcoholic beverages are employed for this purpose by many, for 
alcohol is certainly a cardiac stimulant; it is believed by most to 
lower arterial tension, — a function which is doubtful, at least in pure 
" inflammatory" disorders ; in most infectious fevers arterial tension 
is reduced by toxins which cause a vasomotor peripheral paralysis. 
That would militate against the use both of alcohol and of nitrites in 
the early part of an infectious disease. Moreover, alcohol is believed 
to be an article of food. In the small quantities in which it is ad- 
ministered it certainly is not. Four per cent, of it is eliminated un- 
altered through the lungs, which are thus burdened with that addi- 
tional labor while in a condition of congestion and incompetency. 
Besides, kidney complications, which are not rare in pneumonia, and 
brain affections, which are frequent, particularly in small children, 
contraindicate the use of alcohol. I dare say that the pneumonia of 
a fairly developed infant or child contraindicates rather than de- 
mands the administration of alcohol at an early period of the disease. 
Later, when the conditions change, alcohol may be required in large 
doses, always, however, much diluted. 

Digitalis stimulates and contracts the heart, but also the arteries, 
both the largest and the very smallest, and thereby increases the pe- 
ripheral resistance (more in the old than in the young). A few large 
doses may restore the equilibrium of the faltering circulation, and 
should then be stopped. I have not infrequently given the equiva- 
lent of from one to four grains of digitalis (0.06 to 0.25) in a single 
dose, which was repeated one or more times. This mode of admin- 
istration insures all the coveted effect on the heart and pulse without 
any irregularity, and gives both a result in a few hours and the indi- 
cation to cease, while the usual small doses exhibit their action after 
days only. We may afterwards continue its use in small doses, either 
alone or in combination with strophanthus, sparteine, or caffeine, 
all of which have no such disagreeable effect on arterial tension as 
digitalis ; or we may give them without digitalis. To give doses 
of tincture of strophanthus of less than a drop, or sparteine sulphate 
of less than one-quarter or one-eighth of a grain, every hour or two, 
is useless. Such effect as we require we have a right to demand 
speedily, and the doses should be large enough to enforce it. During 
the last year I made systematic bedside experiments with digitalis 
in acute pneumonias of babies from four months to two years of 



432 DISEASES OF THE RESPIRATORY ORGANS 

age. I take it for granted that the patient should be spared useless 
doses. If a rapid effect is to be obtained, the dose should be just 
short of the over-effect, the symptoms of which can be judged 
nowhere better than when giving digitalis. A reliable tincture was 
given in doses of from one to four drops every hour or every two 
or three hours, with an effect that became marked enough in one 
or two days, and mild enough to allow ample time for a modification 
of the dose. Let it be plainly understood that digitalis is a useless 
drug when given in the small doses recommended by the books. 

Whenever the peripheral circulation becomes insufficient, with 
small pulse, digitalis alone must not be continued ; it should be com- 
bined with nitroglycerin or sodium nitrite, the former in hourly or 
bihourly doses of from one-five-hundredth to one-one-hundredth of 
a grain, the latter in doses of from one-tenth to one-quarter, or these 
remedies may be given alone until the pulse is revived, but no longer. 
They are principally required when the feebleness of the heart is 
mainly perceptible in the right ventricle. There are cases of pneu- 
monia in which the arterial pulse is good, but the external veins 
large, the nails blue, the skin cyanotic, with great dyspnoea and pul- 
monary oedema, together with perspiration, increased cardiac dulness, 
enlarged liver, intestinal oversecretion, and albuminuria, — symptoms 
which point directly to incompetency of the right ventricle. In these 
cases the external circulation must be restored at once, and the ni- 
trites will contribute to fulfilling that indication. So will diuretin 
in doses of from two to ten grains (0.125 to 0.6) administered from 
three to five times a day. Besides, local depletion by leeching will 
sometimes do good. In the adult we should open a vein; a child 
of advanced age may also be saved in this way. It is in these cases 
also that the inhalation of oxygen (better through the nose than the 
mouth, best through a paper bag) and artificial respiration will con- 
tribute a great deal towards saving time and life. 

The distressing cases of catarrhal pneumonia engrafted upon the 
extensive bronchial catarrh or capillary bronchitis of the very young 
will sometimes get well only after we have succeeded in making 
them cry, together with artificial respiration, inviting the respiratory 
muscles to reflex efforts by dashing cold water on them, using for 
brief moments the interrupted current, etc. 

Direct stimulation of the heart may require the use of strych- 
nine in small and frequent doses (a baby of one year not often more 
than a thirtieth of a grain = two milligrammes during twenty- four 
hours), and ammonium carbonate one-half of a grain or a grain (0.03 
or 0.06) in anise-seed water or in milk every half, one, or two hours. 



PNEUMONIA 



433 



In cases of urgent necessity the stimulants should be used subcu- 
taneously, the strychnine sulphate in repeated doses of one-one-hun- 
dredth grain at least, the sodio-salicylate (or benzoate) and sodio- 
cafleine in doses of from one to five grains (equivalent to one-half of 
that amount of caffeine) every one or four hours ; camphor will 
serve the same purpose. Its solutions in alcohol or ether are quite 
painful. I always employ it in four or five parts of sweet almond 
oil; of this I inject from six to twenty drops, according to indi- 
cations ; very slowly, because it passes through a fine needle with 
more difficulty than does a watery solution. 

In connection with these remarks we are enabled to judge of 
the claims of the routine treatment with strychnine, digitalin, and 
aconitine which was imported a few years ago. It is easily perceived 
that it finds its indications like a ready-made coat which fits many, 
but not all, and would not be worn unless first tried on. But a coat 
is not so easily believed to fit everybody as is a newly eulogized treat- 
ment. 

During the last few years creosote carbonate (" creosotal") has 
been recommended in pneumonia as almost a specific. More than a 
dozen cases were treated in a hospital ward. The patients were 
infants from one-half to two years old, and the daily doses amounted 
to twenty or thirty grains (1.5 or 2.0) . I cannot say that the cases ran 
a more favorable course than under other treatment; in some I was 
compelled to resort to active cardiac stimulation. 

When, during hepatization and the period of incipient resolution, 
expectoration is insufficient, the remedy is inhalation of steam, with 
or without turpentine. The latter may be spread through the room 
by means of large sponges, or on towels which are soaked with it, 
or it may be evaporated on boiling water. The easiest way is to 
fill the whole room with the vapor. Inhalers are insufficient and 
annoying. Give camphor, aqua camphorae in teaspoonful doses or 
more, or one-quarter- to one-grain doses in diluted mucilage, or 
benzoic acid powders in the same doses, or ammonium carbonate. 
Ipecac may derange the stomach, senega is either an adjuvant or 
a placebo. Drinking of plenty of water, mainly alkaline waters, — 
Seltzer, Vichy, Poland, — also doses of sodium bicarbonate or potas- 
sium iodide, will increase and liquefy the bronchial secretion. Am- 
monium chloride is of but little use in hepatization; but evaporated 
in amounts of ten or twenty grains every few hours on a hot stove 
or over a flame, it fills the room with a white cloud which greatly 
stimulates the bronchi. Warm poultices will serve the same purpose. 
Their place is during hepatization for the purpose of aiding absorp- 

28 



434 DISEASES OF THE RESPIRATORY ORGANS 

tion, not in the first stage of pneumonia. When nursing is insuffi- 
cient, and there is danger of wetting the clothing and bedding, it is 
best to substitute for them a cotton- wadding jacket, covered or not 
with oil silk or, better, flannel, which protects against exposure and 
keeps up a uniform temperature of the skin. When hepatization 
is completed and absorption is slow, the indication is to give iodides 
a long time. 

Pleural pain is relieved by gently strapping the chest, when tol- 
erated, — it mostly is, — by sinapisms, which must be kept on a few 
minutes only and repeated from time to time ; warm poultices ; a 
few doses of sodium salicylate or phenacetin ; in urgent cases by 
a subcutaneous injection of morphine. Vesicatories are injurious; 
they chafe, irritate, and annoy. Their only — rare — indication is in 
the long persistence of hepatization, with or without chronic pleurisy. 

Irritating, hacking cough demands small doses of opium. Much 
of this cough is pharyngeal, and is relieved by frequent drinking 
of small quantities of water. Sleeplessness and great general irri- 
tation require a dose of opium for the night. A sleep of an hour 
or two affords great relief to the cough and to all the symptoms. As 
a general rule, however, the habit of giving opium in the first stage 
of pneumonia is a bad one. Rest should not be bought with death. 

The bad odor of complicating gangrene indicates inhalations of 
turpentine, eucalyptol, or carbolic acid ; the presence of abscesses 
in the lung demands surgical interference, unless there be a sponta- 
neous rupture through a bronchus. Most abscesses are within reach 
of the knife and actual cautery, for generally there is a sufficient 
amount of pleural adhesion to render access devoid of much danger. 

The prognosis of operations on pulmonary abscesses depends on 
their age and nature. Acute abscesses give a better prognosis than 
chronic, simple abscesses (though complicated with bronchiectasis) 
a better one than those which are putrid. Those depending on for- 
eign bodies are not favorable, those originating in tuberculosis still 
less so. The latter are frequently multiple. Operation on the lung 
should be preceded by the resection of a rib. It is facilitated by pleu- 
ral adhesion, but rendered difficult by the uncertainty of localization 
through percussion and auscultation. Deep-seated abscesses should 
be reached with the actual cautery, to avoid hemorrhage. On a col- 
ored girl of four years, however, I operated for deep-seated gan- 
grene of the lung with the knife, being sure beforehand that the lung 
between the abscess and the chest-wall was carnified, though the 
expectoration was very bloody. 

Complication with malaria, which is mostly rare, but was quite 



PNEUMONIA. EMPHYSEMA 435 

frequent in New York in 1898 and 1899, requires quinine, best during 
a remission ; intermittent pneumonia, which is also uncommon, qui- 
nine and ergot; complication with nephritis contraindicates digitalis 
and alcohol, and suggests the substitution therefor of sparteine, cam- 
phor, and nitroglycerin; in atelectasis the stronger stimulants are 
required, and artificial respiration by the different methods; the 
patient should be made to cry ; cerebral disease, when acute, indicates 
ice and purgatives and bromides ; when chronic, potassium iodide. 

Hypostasis and hypostatic pneumonia, so common in infectious 
diseases and in conditions of great debility, require frequent changing 
of position from one side to the other and the early administration 
of stimulants in large doses, together with friction of the entire 
surface with cold or hot water or with alcohol and water. The most 
powerful of all internal stimulants — musk — should be given fre- 
quently, — viz., every half to one or two hours, — in doses of from 
one-half to two grains, until from six to fifteen grains (0.4 to 1.0) 
have been taken in the course of half a day. 

Interstitial pneumonia is treated on the general principles laid 
down above. Later, potassium iodide in sufficient doses, a mild 
tincture of iodine externally, and an occasional vesicatory. When 
it has become chronic, digitalis may be given for months in small 
doses to keep up both a sufficient circulation through the indurated 
lung and a competent nutrition of the heart muscle, and potassium 
iodide alternating with iodide of iron. Persistent and careful pul- 
monary gymnastics should be continued for years. 

Non-tubercular pulmonary phthisis should not be considered a 
nosological entity; it is the result of a variety of causes, such as 
primary bronchiectasis, or fibrous, syphilitic, or actinomycotic degen- 
eration (p. 439). The fibrous degeneration is mostly due to protracted 
or repeated pneumonias terminating in carnification, multiple cica- 
trices (which may surround either healthy or atelectatic pulmonary 
tissue), and in many cases of pigmentation. Bronchial and pulmonary 
ulcerations are met with after both fibrinous influenza and pneumonia. 
Hansemann states that one of the principal causes is chronic lymphan- 
gitis. 

Emphysema of the infant lungs, sometimes not easily diagnos- 
ticated because of the size of the liver and of abdominal tympanites, 
and never unless percussion be performed very, very gently, is often 
overcome by the elasticity of the pulmonary tissue, and therefore 
its prognosis, no matter whether produced by forced inspiration (in 
pneumonia) or by forced expiration (severe attacks of coughing), 
or even that rare form which results from ill nutrition of the alveoli, 



436 DISEASES OF THE RESPIRATORY ORGANS 

is not so bad as it mostly is in adults. Its treatment is that of chronic 
catarrh, and by gymnastic exercise of the respiratory muscles and 
general roboration. Besides, forcible expiration ought to be prac- 
tised extensively; during expiration the chest-wall ought to be well 
compressed. Snuff should be used half a dozen times daily, and 
copious sneezing procured. Expiration into the rarefied air of one 
of the many pneumatic apparatuses is also recommended. It may be 
tried on tractable children. 

Pulmonary oedema requires the causal treatment of its origin, 
which can be traced to cardiac, pulmonary, or renal disease. Urgent 
cases — for the disease may prove fatal in a short time — require dry 
cupping, now and then the emptying of the lungs by an emetic (apo- 
morphine subcutaneously when vitality is low and the expelling mus- 
cles are unable to act), and stimulation of the excreting organs and 
of the heart. A powerful purgative — calomel, croton oil, or elaterium 
— is an active derivant. Digitalis in large doses (a few minims of 
the fluid extract at once) will stimulate the heart. Sodio-caffeine 
salicylate or benzoate, in subcutaneous injections, from one to five 
grains (0.05 to 0.3), repeated five or six times at intervals of 
fifteen minutes, acts beautifully. Lead acetate stops oversecretion in 
a good many instances. Pilocarpine (from one-twentieth to one-sixth 
grain) subcutaneously has relieved, and saved, many a case resulting 
from renal disease. 

Pulmonary hemorrhage is not frequent, for tuberculosis of the 
young lung produces induration and vascular obstruction rather than 
cavities : and though whooping-cough gives rise to hemorrhages, they 
are tracheal and bronchial rather than pulmonary. Cardiac diseases 
may lead to venous obstruction and thereby to hemorrhages. Digi- 
talis, lead, alum, ergot, narcotics (mainly opiates in quieting doses), 
and ice temporarily to the chest, with a hot (mustard) bath of the 
lower half of the body, as well as' absolute physical and mental rest, 
are indicated. Demelin collected twenty-two cases occurring in the 
newly-born (Rev. Obst. Internat., January 1, 1897). They were 
either speedily fatal or gave rise to alleged melrena (blood swal- 
lowed). 

Infarction, with its sudden onset and vehement dyspnoea (some- 
times chill), is, in the newly-born, the result of embolism from the 
umbilical vein or the ductus arteriosus ; later from a marantic throm- 
bosis of the sinus, the renal, femoral, or portal vein, or from caries 
of the petrous or some other bone, from valvular disease, from an 
infectious malady, or from an extensive burn. The causal indications 
must be obeyed, if possible. Ice applications to the affected part, 



(EDEMA. HEMORRHAGE. PSEUDOPLASMS. HERNIA 437 

opiates and digitalis, and stimulants when required, symptomatic 
treatment afterwards (antipyretics). 

Some of the cases are followed by gangrene. This condition, 
however, generally results from the presence of foreign bodies, from 
acute infectious diseases, — diphtheria, measles, noma, typhoid, — or 
from (mostly lobular) pneumonia, also after infarctions. A few 
cases are also on record as having resulted from careless pneumatic 
treatment. Mineral acids largely diluted with water, as also quinine 
and lead, have been copiously used. Besides stimulants given to the 
required extent, I have relied mainly on inhalations of turpentine, 
either from a paper bag in which a sponge was kept soaked or from a 
kettle with boiling water, or of terebene ; internally, of terebene, from 
twenty to fifty drops daily, or creosote a few drops daily. Latent 
pulmonary gangrene, not connected with a bronchus, may exhibit 
no odor, but great general asthenia (Martinez Vargas in Festschrift). 

Such pseudoplasms as have been or may be observed in the young 
lungs demand treatment on general principles. Carcinoma has been 
noticed a few times, also in the mediastinum. Sarcoma is more 
common, mostly in the pleura. The treatment should consist in in- 
creasing doses of arsenic, and in the injection, according to Coley, 
of the toxin of the coccus erysipelatos and bacillus prodigiosus. 
Echinococcus of the lungs and pleura (fluid without albumin and 
sodium chloride, and with scolices) demands free incision, resection 
of a rib, and drainage. Puncture and the injection of Lugol's 
iodine solution do not suffice. J. von Bokay (Festschrift) performed 
Baccelli's operation between the fourth and fifth ribs in the left axilla. 
He removed thirty cubic centimetres of the fluid, injected twenty 
cubic centimetres of a one-per-mille solution of corrosive sublimate, 
and repeated the operation after four weeks. Recovery. Actinomy- 
cosis has been reported by Soltmann : the case occurred in the pos- 
terior mediastinum of a boy of six years ; also by Karewsky. It 
may remain unrecognized, " latent" inside the lung, may perforate 
to the surface and through the chest, or may gain access to the ab- 
domen and cause metastases. Potassium iodide and operation. 

Hernia of the lungs has been observed below the clavicle and 
on the back. The soft, elastic tumor changes its size with respiration. 
In such cases the lung is either normal or emphysematous. The 
cough disappears after the application of proper bandages. De- 
formities of the chest- wall, with or without a defect in bones (ribs or 
sternum — Ussura stemi congenita — ) or muscles (pectoral), particu- 
larly the funnel chest, in which the lower part of the sternum is, 
by an arrest of development occasioned by the pressure of the em- 



438 DISEASES OF THE RESPIRATORY ORGANS 

bryonal head while amniotic liquor is scanty, so drawn in as almost 
to touch the vertebral column, can never be removed, but the con- 
secutive contraction of the intrathoracic space can be partially counter- 
balanced by systematic gymnastics and functional improvement of the 
lungs at an early age. 

5. The Intrathoracic Lymph-Bodies. 
In close connection with the congestive and inflammatory diseases 
of the thoracic organs are many changes in the bronchial and medi- 
astinal lymph-bodies, which can more easily be prevented than cured. 
A protracted catarrh of the bronchi results in glandular hypersemia 
and hyperplasia; a nasal catarrh of the newly-born and the nursling- 
descends rapidly with the same effect, or the consecutive glandular 
tumefactions of the submental and submaxillary regions implicate 
the adjoining tiers of lymph-bodies ; rhachitis, scrofula, and tuber- 
culosis are also causes of bronchial and mediastinal adenitis. Bacilli 
may reach the lymph-bodies through the mucous membrane of the 
bronchi, though its epithelium be intact. Pressure on veins and 
nerves, occasionally with dilatation of one or both pupils, also on 
the trachea; attacks of coughing without crowing inspiration; fre- 
mitus, feeble or increased; respiration, increased and bronchial or 
feeble; dulness over the sternum down to the second rib, but not 
extending to the exterior margin of the lungs ; dulness posteriorly 
about the hilum of the lungs, more marked to the left than to the right 
(location of thoracic duct on the left), are among the principal symp- 
toms. Pressure on the trachea or on one of the large bronchi may 
be such as to cause an actual stenosis and suffocation. Fever, if 
present, depends on complications or on absorption from the glands 
while undergoing changes. Abscesses may cause pyaemia, or perforate 
into the oesophagus, or the trachea, or a lung. Antirhachitical, anti- 
scrofulous, and antitubercular treatment are the indications. Mercu- 
rial ointment, potassium iodide ointment, inunction of green soap, 
potassium iodide internally, iodide of iron, increasing doses of arsenic, 
ice externally if there be any local pain, and the treatment of sequelae 
or complications (catarrh, lobular pneumonia, dyspnoea, protracted 
fever) are demanded, but will not always prove successful. 

6. The Pleura. 

Pleuritis is of frequent occurrence during the first decade of life ; 

empyema is, indeed, more common during infancy and childhood 

than in advanced age. The majority of cases of pleuritis which occur 

in the newly-born are secondary, of pyaemic origin, and depend 



INTRATHORACIC LYMPH-BODIES. PLEURITIS 



439 



mostly on umbilical phlebitis; still, cases with serous, and the usual 
forms of purulent, secretion are not uncommon in the very young. 
Pleuritis may be the direct result of exposure ("cold"), of contu- 
sion, of broncho- and fibrinous pneumonia, of pericarditis and peri- 
tonitis, or of a neoplasm (then the effusion is mostly hemorrhagic). 
It frequently accompanies pulmonary tuberculosis (often " dry," 
rarely serous, more frequently sanguineous), diphtheria, acute rheu- 
matism, and eruptive fevers. Thus, there is but rarely a causal 
indication for treatment; prevention is best secured by giving the 
utmost care to the management of those diseases which cause its 
outbreak. Its symptoms are often deceptive, for even pain is not 
always present, though it is one of the most frequent occurrences. 
The pain is sometimes quite local ; at other times, however, it extends 
over a large surface. Its locality does not always correspond with the 
seat of the pleuritis. For instance, the extension of the peripheric 
ramifications of the intercostal nerves is so great that the children 
often complain bitterly of epigastric pain down to the umbilicus on the 
affected side. The disease requires absolute rest and immobilization of 
the chest. Broad strips of the usual varieties of adhesive plaster, which 
irritate the surface and render local applications difficult, are inferior 
in value to the plasters prepared with zinc. A broad bandage or a 
moderate-sized towel fastened round the chest with safety-pins is 
more appropriate and is well tolerated. An ice-bag applied to the 
diseased region will often render the best service; it must not, 
however, come in contact with the bare skin. When no bandaging 
is required, a cloth well wrung out of cold water, of the size of half 
a square foot, more or less, or surrounding the whole chest, may 
be applied every fifteen or thirty minutes. It should be covered with 
rubber cloth and flannel. In very bad cases the pain should be re- 
lieved by a subcutaneous injection of morphine; its internal adminis- 
tration is generally useless and sometimes hurtful. Local depletion 
by cups or leeches I have rarely used these thirty years ; dry cupping 
may relieve such children as are old enough and intelligent enough 
not to get excited and not to harm themselves by screaming and 
active resistance. Mustard-plasters must not remain longer than a 
few minutes, and may be repeated every few hours. Warm fomen- 
tations will relieve anaemic and feeble children; they ought, how- 
ever, to be avoided in the beginning of the disease, when the indi- 
cation to limit congestion and secretion is paramount. A dose of 
calomel sufficient to relieve the bowels (sometimes followed by an 
opiate) and sodium salicylate in doses adapted to the age of the 
patient are the remedies which will bring relief. The salicylic acid 



440 DISEASES OF THE RESPIRATORY ORGANS 

in the latter is not present in sufficient doses to lower blood-pressure 
to an uncomfortable degree. Vesicatories are much less indicated 
in the first stage of pleuritis than perhaps later; they always irri- 
tate both the skin and the patient, cause sleepless nights, and add to 
the discomfort of the patient, and discomfort and sleeplessness impair 
the prognosis. If there were a benefit to be derived from blistering, 
the condition of the pleura might be improved, perhaps, but the sick 
injured, probably. 

If the temperature be so high as to injure the patient, antipyretics 
should be given. Probably from three to ten grains of quinine admin- 
istered before noon will lower the afternoon rise. If required, a 
dose of phenacetin, with or without a moderate dose of codeine, may 
be given at eight or ten o'clock at night. 

When the fever decreases, or when the heart begins to get weak 
previously, digitalis, strophanthus, sparteine, or caffeine, with or 
without ammonium carbonate or camphor, is indicated; no improve- 
ment, either through diaphoresis or diuresis, need be expected so long 
as the heart remains weak. The choice between the caffeine prepara- 
tions is a matter of indifference. The salicylic acid in the double salt 
(Na -f- Caffeine) is not sufficient to depress the heart's action. At the 
same time an acetate, or a citrate, or an iodide may be given. Pilocar- 
pine, which has been recommended, is a two-edged sword, and re- 
quires a stronger -constitution than almost any baby and most older 
children can boast of ; in pleuritis there is no vital indication that can 
be fulfilled by pilocarpine to such advantage as may be derived from 
it in certain cases of acute pulmonary or intracranial oedema. Ex- 
ternally, at this period, tincture of iodine diluted with alcohol may 
do some little good, particularly in cases of " dry pleuritis." It is 
this form mainly which will be benefited by warm fomentations and 
the use of iodides. When the main indication is to absorb effusion, 
abstinence from drinking, and the use, in fair doses, of table salt, 
which increases diuresis, will be found useful. Diuretin, in four 
daily doses of from two to five grains (0.125 to 0.3) or more, may 
stimulate the action of the kidneys to such an extent as to result in 
the absorption of the pleural effusion. Milk-sugar in drachm doses, 
as much as an ounce daily, may be given as an adjuvant to increase 
diuresis. 

The indications for operative interference with the pleural effu- 
sions, no matter of what description, are various. It is demanded 
when the difficulties of either respiration or circulation, or both, 
require immediate relief. The latter may suffer even without the 
participation to a great extent of the former. Indeed, Trousseau 



PLEURITIS. OPERATIONS 441 

describes a case of fatal collapse due to nothing but disordered 
circulation. Among the symptoms urging the operation are intense 
dyspnoea, cyanosis, diminution of the renal secretion, anasarca and 
ascites, and a considerable dislocation of the heart or the liver. In 
many cases the intercostal interstices are no longer visible, either 
on inspiration or expiration; they are even found bulging. Not in 
every case are the consecutive disorders proportionate to the amount 
of effusion; indeed, this may be small compared with its effects 
when the pleuritis is complicated or secondary to a disease of either 
heart or kidneys, or both. Still, the quantity of fluid contained in 
the pleural cavity is more frequently underestimated than the reverse, 
no matter whether the healthy lung is pressed upward and is float- 
ing on the liquid in a compressed condition, or whether, congested 
Or inflamed, it is swimming in the midst of the fluid or adheres in 
places to the chest-wall. Thus, it is impossible to exactly gauge the 
indications for the operation according to the amount of effusion. 
Potain's assertion, that when the latter reaches the level of the clavicle 
the operation should be performed, is justified by the fact that the 
consecutive symptoms in the majority of such cases are very urgent. 
In most cases we should not wait quite so long. In such persons as do 
not subjectively complain, indifference is mostly due to lack of cerebral 
perception, — in conditions of unconsciousness during meningitis, 
typhoid fever, or idiocy. When the dulness extends high up both 
anteriorly and posteriorly, and no absorption takes place within a few 
weeks, the operation is required. The longer the compression of the 
lung has lasted the smaller will be the chances of its reinflation. It 
is true, however, that now and then it will re-expand after com- 
pression has lasted two or three months. Another serious danger 
accompanying the pressure produced by the liquid is the inactivity 
of the blood- and lymph-vessels of the walls of the cavity; for in 
such a case total compression means absence of function (absorption). 
Thus, even a partial removal of the fluid, with partial relief to the 
vessels, is quite often the first stimulus to absorption and the com- 
mencement of recovery. 

In order to either make or confirm the diagnosis of exudative 
pleuritis, an explorative puncture is often resorted to; for, in spite 
of a number of rational symptoms, the positive diagnosis of a pleural 
effusion or exudation is sometimes impossible without its ocular 
confirmation. The puncture is made near the upper edge of a rib 
to avoid the course of the intercostal artery, while the hand of the 
diseased side is carried to the opposite shoulder to widen the inter- 
costal spaces. The pain of the little operation is diminished by the 



442 DISEASES OF THE RESPIRATORY ORGANS 

quickness of its performance; besides, a slow introduction of the 
needle — particularly when of larger size — may peel off the pleura 
from the chest-wall. In many cases of copious exudation the place 
selected, within certain limits, is a matter of indifference. The 
puncture is mostly made where there is bulging, or a high degree 
of dulness, or more or less complete absence of respiratory murmur, 
frequently in the sixth intercostal space posteriorly to the axillary 
line. When these spaces are narrow, or when the patient is restless, 
it is not always easy to penetrate them ; these are the cases in which, 
now and then, the intercostal artery has been wounded, or pain 
resulted from hitting the periosteum. When the point of the needle 
is not carried far enough, it may land in the chest-wall or in the thick- 
ened pleura; when too far, it reaches the lung; when in a wrong 
direction, it may be fastened in the liver or in the spleen. In such 
cases the needle is liable to participate in the excursions produced by 
inspiration and expiration, and, when withdrawn, will carry blood 
instead of the contents of the pleural cavity. In rare cases it is 
possible, however, to exhibit the latter and still wound the lung. It 
has happened to me to extract pus from a pyothorax. On the very 
spot of the puncture the incision was made and a rib exsected ; when 
the incision through the pleura was made, there was bleeding from 
the lung. The wound was closed with iodoform gauze, a new punc- 
ture was made at a different locality, pus was found, the rib exsected, 
and again there was, on incision, pulmonary hemorrhage, which also 
was stopped by compression with iodoform gauze. A third puncture 
and a third excision at last led directly into the empyema. The fail- 
ures were due to extensive pleural adhesions, and the deceptive results 
of the exploring punctures to the fact that the needle did not reach 
pus until it had perforated the adhering and twisted lung. Punctures 
of the lung need not result in hemorrhages, but there are enough 
cases of the kind to enforce the greatest care. 

While an absolute diagnosis cannot always be made without a 
puncture, the results of the latter are sometimes not conclusive. 
Though there be plenty of liquid (serum, pus, blood) in the cavity, 
it may not always follow the sucking piston. The point of the 
needle may first land in the lung after passing through liquid; this 
will enter the instrument only while the needle is being slowly with- 
drawn, provided again that it has not been closed by a blood-clot. 
Therefore, when the puncture is futile, the needle ought to be care- 
fully examined as to its perviousness ; or the needle is too thin 
for the contents; pus is quite often present where serum was ex- 
pected; or the needle is caught in thick fibrinous deposits. That 



PLEURITIS. OPERATIONS 443 

may happen time and again, and lead to serious miscalculations and 
mistakes. Or the pleuritis may be localized, and result in an en- 
cysted empyema instead of a general pyothorax. Such localized 
empyemata are more frequently met with posteriorly, and upward 
(but sometimes anteriorly), than low down, where they are usually 
expected, on account of the fact that it is there that free pleural 
fluids are found. They are quite small sometimes, and not infre- 
quently multiple, and therefore hard to find. Puncture after punc- 
ture must be made in such cases as yield all the rational symptoms 
of pyaemia, including leucocytosis in examinations of the blood, and 
when no pus can readily be detected. When finally found, it is 
not always certain to come from a pleural abscess, after all. It may 
be derived from a small pulmonary abscess, or from a pyopneumo- 
thorax. In the latter instance, however, and sometimes in the former 
also, there is often air (or gas) found mingled with the pus. 

There are other possibilities of mistake. The needle may have 
withdrawn serum only, and yet pus or blood may be present; for 
in patients who have been in a recumbent or semi-erect position, as 
usual with pleuritics, the solid constituents of blood and pus will be 
deposited near the diaphragm. Thus, a microscopic examination 
ought first to complete the diagnosis of the nature of the pleural 
contents. When pus has been found, there is an urgent indication 
not to procrastinate the radical operation, for the puncture channel 
may become the cause of pus-infiltration, and possibly of pyaemia. 
Particularly is this so when the pus is discolored and malodorous, 
as it is apt to be in cases of pyopneumothorax, or in those which 
are complicated with caries. The latter cases are apt to be at- 
tended by high temperatures (still, there are exceptions), the fever 
being either continuous or irregularly intermittent. Such fevers re- 
quire an exploring puncture at an early date; it is mostly delayed 
too long. Indeed, every case of uncomplicated pleuritis in which 
a high temperature is incessant for four or five days, mainly when 
complicated with much pain or local oedema, becomes suspicious. 
Even as early as the fourth day I have met with large amounts of 
pus, not only in infants and older children, who are more apt to de- 
velop pleural suppurations, but also in adults. These are sometimes 
instances of double empyema. Though it is not frequent, it should 
be thought of in cases of unusual severity. Moderately high tem- 
peratures, however, do not necessarily indicate the use of the needle, 
for through periods of weeks temperatures of 1003/2 ° or 101 F. may 
persist without meaning anything but the systematic irritation caused 
by a perpetual process of absorption and elimination. Thus, after 



444 DISEASES OF THE RESPIRATORY ORGANS 

all, there is no positive certainty that can be conveyed to the un- 
thinking ; here it is, as everywhere in medicine, that experience comes 
handy, when guided by brains. 

Before the operation of puncturing is performed, the skin must 
be thoroughly washed (and disinfected) ; after the needle has been 
withdrawn, iodoform gauze, or bismuth subcarbonate (or some other 
disinfectant powder), or a sterile gauze is applied to the wound and 
covered with adhesive plaster or a bandage. If there be pain, ice is 
applied. At all events, the chest ought to be at rest; the patient, 
if possible, in bed; no exercise or work permitted for a day. As 
a remedial agent a simple puncture is of no account. When recovery 
follows an exploring puncture, it is spontaneous, and not induced 
by it ; for spontaneous absorption of the pleural fluids, both of trans- 
udations and exudations, is quite frequent. That is mainly so when 
the liquid is serous only and not too excessive; in the latter case, 
absorption begins only when, by means of an aspiration, the pressure 
by which blood- and lymph-vessels are hampered has been in part 
relieved. Nor is it infrequent for hemorrhagic exudations, or even 
extravasations, to be absorbed after the solid constituents have been 
deposited on the surfaces of the pleurae. Even the results of tuber- 
cular pleuritis may disappear, just as ascites caused by tubercular 
peritonitis is apt to get well whether or not tubercle bacilli are found 
in the fluid. As a rule, in most of the cases of spontaneous recovery 
no microbes are present ; if they be found, they are mostly the short- 
lived cocci of Fraenkel. No such favorable event, however, need 
be looked for when the long-lived streptococcus and staphylococcus 
are present ; still worse is the influence of proteus vulgaris and mira- 
bilis in putrid empyema. Simple encysted empyema, however, may 
finally heal without any operative interference, through a process of 
gradual inspissation and absorption ; but it is not advisable to expect 
it or to wait for it. 

Spontaneous perforation of pyothorax, either through the lungs 
or through the chest- wall, may lead to recovery ; but it is slow, and 
takes place at the expense of much time, suffering, tissue, and usually 
of future health and vigor. It should never be wished or waited for. 
Other perforations may take place into the oesophagus, the pericar- 
dium, or the abdominal cavity. Thirty years ago I saw, with Dr. L. 
H. Sayre, an empyema we had to open in the right gluteal region. 

Thoracocentesis ought to be performed soon after the exploring 
puncture. In many cases, when a mere aspiration is made, the opera- 
tion appears simple enough; but it ought to be considered serious 
in all cases, as in many it is. The patient must rest quietly and be 



PLEURITIS. OPERATIONS 



445 



well supported in the position recommended for a simple puncture, 
and so that respiration and circulation are not unduly interfered 
with. The needle is inserted with the precautions detailed in the 
remarks I made on puncture; if it be caught by a fibrin clot, the 
latter may be detected by a probe introduced through the needle, but 
a second insertion may be required, probably anteriorly and superiorly 
to the first one. Aspiration alone will not cure empyema, except occa- 
sionally in infants, whose ribs are flexible and whose chests can be 
compressed more readily so as to approximate and adjust the walls 
of the abscess ; even in them, however, the same operation must not 
be repeated after pus has again been formed, but a more extensive 
and radical operation is to be undertaken. Aspiration is always 
contraindicated in the empyema of adults, except in a vital indication 
for temporary relief, or when the fluid is hemorrhagic in character, 
or in cases absolutely inoperable by a more radical method. 

During the operation the patient, if it be feasible, ought to be 
kept as much as possible on the diseased side, so as to avoid the 
dyspnoea due to the compression of the lung of the opposite side 
and the molestation of the heart. The fluid may be permitted to flow 
so long as the current remains equable during inspiration and expira- 
tion; the discharge must be stopped when the current begins to 
cease during inspiration. The relief given by the removal of a half- 
pint or a pint is sometimes considerable ; but in young children, 
with their compressible chests and corresponding facility of accom- 
modation to the expanding lung, it is safe and advisable entirely to 
empty the cavity. If the operation — because of the urgency of indica- 
tions — be performed while exudation is still progressing, and dysp- 
noea return, another thoracocentesis may become necessary within a 
short time. I had to operate twice within a day. If the contents 
be hemorrhagic (from tuberculosis, carcinoma, alcoholism, nephritis, 
a rare occurrence in childhood), as little as possible should be with- 
drawn. 

The operation requires time. It is advisable to interrupt the dis- 
charge from time to time ; for the too rapid entrance of air into the 
bronchi causes violent attacks of coughing (erroneously attributed 
to the needle irritating the pulmonary pleura), or the sudden rush 
into the expanding lung may give rise to large quantities of serous, 
strongly albuminous, bronchial secretion, or to copious pulmonary 
oedema, or to hemorrhages with slight surface lesions, or even to 
considerable rupture of pulmonary tissue. Fainting spells are also 
frequent during a rapid escape of serum, sometimes through psychical 
influences, sometimes from cerebral anaemia. In other cases (fortu- 



446 DISEASES OF THE RESPIRATORY ORGANS 

nately rare) thrombi formed in the compressed lung, or in the im- 
peded heart, or in the torn surface of the bronchi may be carried 
into distant blood-vessels ; thus, emboli are known to have been swept 
into the pulmonary artery or into the artery of a fossa Sylvii. 

After the operation the wound must be cared for as I suggested 
above, when speaking of the treatment of a mere puncture made for 
the purpose of a diagnosis. In addition, it is advisable to enforce 
absolute rest and to apply for some time an ice-bag to the part. This 
is particularly necessary when there is acute pain. Should this be 
severe, morphine may be used subcutaneously, but in uncommonly 
small doses, because its absorption is very rapid and its effect much 
more marked here than under ordinary circumstances. 

The simple operation of aspiration does not suffice in cases of 
exudative pleuritis in which the pleural contents hold, or consist of, 
pus, either laudable or putrid. As I mentioned before, pus may be 
found as early as the fourth day, and then it is often on both sides. 
When high fever attends such cases, far from contraindicating a radi- 
cal operation, they require it for immediate relief. If such relief be 
not obtained after a reasonable time, it is either because of a compli- 
cation, such as pneumonia, pericarditis, or peritonitis, or of some pus 
concealed in a recess. The latter ought to be looked for and made 
to discharge; Nelson employed a metal sound for the purpose of 
breaking up adhesions and facilitating the escape of pus. 

The radical operation consists in the making of a large aperture, 
either by a simple incision between two ribs, if possible, in the fifth 
or sixth intercostal space between the mammillary and axillary lines, 
or by incision with the exsection of a piece of rib from one-third 
of an inch to an inch in length, large enough to admit two fair-sized 
drainage-tubes. The opening is insufficient so long as it gives no 
exit to the clots of fibrin, which are sometimes as large and perplex- 
ing as their presence is unsuspected. It is on their ready and speedy 
removal that the duration of convalescence or the favorable or fatal 
termination depends. Therefore, they should be removed at the time 
of the operation. There is no better means than to dislodge them 
from the surface of the lung and of the chest-wall by the index-finger 
introduced into the cavity. During the following irrigation they are 
washed out or appear at the opening and may be caught in a forceps. 
There are those who, as the presence or absence of these large masses 
cannot be diagnosticated, insist upon exsection in every case of 
empyema, no matter whether of recent date or of long standing. 
At all events, whenever there has been a continued or a pysemic fever, 
a great deal of pain, an intercostal oedema, or a complication with 



PLEURITIS. OPERATIONS 



447 



infectious embolism, pyopneumothorax, tuberculosis, or superficial 
pulmonary or hepatic abscess, the exsection of a large piece of rib 
is indispensable. After the operation has been completed, the cavity 
may be thoroughly washed with quarts of warm saline (6 to iooo) 
or of Thiersch's solution. Stronger antiseptics should be avoided, 
or used only — largely diluted — when the fluid is decomposed. In 
the latter case irrigations are indispensable; they may be dispensed 
with altogether when pus is absolutely laudable and the patient in a 
low condition. The dressing should be soft, thick, and aseptic. The 
frequency of the removal of this dressing and the number of injec- 
tions depend on the nature and quantity of the pleural secretion. 
In the majority of cases it is safe to wait until the dressing becomes 
moist. When the lungs expand readily, many days may elapse before 
the first dressing is removed and another one substituted. In most 
cases no irrigation is required after the one which terminates the 
operation. For the sake of thorough drainage, the patient should, 
however, be placed horizontally (the incision being the most de- 
pendent part) with raised hips, at least three times a day, and ordered 
to cough as hard as possible (Koenig). When, however, the pus 
is putrid, and in cases of complications such as are mentioned above, 
a daily change of dressing and daily irrigations, with occasional short 
interruptions, should take place. To expand the lungs and to promote 
the required adhesion between the pleurae, the child should amuse 
himself with blowing soap-bubbles, trumpeting, or with W. T. James's 
entertaining exercise. He is made to blow air into a bottle and dis- 
lodge the water (colored with fuchsin, methylene-blue, or such like) 
into another one by means of a simple system of rubber tubes. When 
fistulas remain behind, or the abscess cannot close because of the lung 
being kept from expanding by pleuritic thickening over it, larger 
pieces of one or more ribs must be removed to enable the chest-wall 
to sink in and thereby facilitate the approximation of the walls of 
the cavity. In these, as in many simpler cases, it is necessary to keep 
the opening patent for a long time; this is readily accomplished 
through the slowness of the growth of callus in that region. To 
render the expansion of the lung possible, J. D. Bryant (Festschrift) 
exhausts the air and empties the contents of the cavity by means of 
a closely fitting rubber apparatus, aided by adhesive straps. 

The hemorrhage complicating the operation for empyema is rarely 
copious ; but it should be stopped, as the patient is not in a condition 
to lose blood. A severe hemorrhage coming from numerous granu- 
lations on the pulmonary pleura I had to stop by filling the cavity 
immediately with large quantities of sterile gauze. 



448 DISEASES OF THE RESPIRATORY ORGANS 

Other hemorrhages of the pleura may be due to the presence of 
neoplasms or to grave septic fevers. In variola and lead or phos- 
phorus poisoning they may be complicated by fatty degeneration of 
the liver, the kidneys, the heart, and the pancreas. Others are angi- 
opathic, — in hysteria, in obstructed general circulation, and in suffoca- 
tion. 

Hydrothorax (fluid with a low specific gravity, less than 1015, 
and from one to five per cent, of albumin) depends on or is compli- 
cated with malaria, nephritis, cardiac disease, anaemia, or cachexia. 
The cases resulting from scarlatina are among the most favorable. 
Besides the indications afforded by its cause, and good nutrition, 
hydrothorax demands diuretics, such as digitalis, sparteine sulphate, 
caffeine, diuretin, and potassium bitartrate. The less such patients 
drink the more readily will the fluid be absorbed. Plenty of sodium 
chloride in food and drink will increase renal action. If no reduction 
of the fluid take place, paracentesis is demanded. 

Pneumothorax is a complication or a result of the perforation 
of a cavity, of pulmonary gangrene, of pleural infarction, or of per- 
forating empyema, and in many cases of this kind pyopneumothorax 
will be observed. Foreign bodies are more apt to produce pneumo- 
thorax than whooping-cough, which is liable to tear the mediastinum 
rather than the pleura. Ice will relieve local inflammation and pain, 
so will opium, which, moreover, modifies the perturbed respiratory 
movements. Cases of pyopneumothorax which do not readily discharge 
their pus through the lungs demand a counter-opening of the chest- 
wall, which should be made, not under a general but a local anaes- 
thetic. Subcutaneous emphysema is occasionally observed in pyopneu- 
mothorax ; it is a disagreeable but not dangerous complication. 



Diseases of the Organs of Circulation 

I. The Heart. 
Both in acute and in chronic diseases of the heart the amount 
as well as the quality of food require some modification. In many 
cases the loss or diminution of appetite will regulate the former. As 
a rule, however, the amount taken ought to be much less than the 
same person would take when in health. Not only ought the total 
quantity to be less, but also that consumed at each meal should be 
comparatively small. It is best, therefore, to divide the meals into 
halves and even thirds, so as to cause the patient to eat every two or 
three hours. Digestibility must be improved by slow eating. The 
diaphragm should not be annoyed by large quantities of food or by 
the evolution of gases. Therefore but few carbohydrates (very little 
fat) are to be given at one time, and the digestion of nitrogenous 
foods, such as meats (eggs) and milk, with or without cereals, 
ought to be aided by pepsin and dilute hydrochloric acid. The latter 
is an excellent adjuvant to the digestion of milk prepared according 
to J. Rudisch's formula (p. 34). Or it may be modified or mixed 
according to other rules given by me in the first chapter of this book. 
At all events, milk is the main food to be given in cardiac ailments. 
Its digestion has a further advantage in this, that it does not result 
in the physiological congestion of the stomach, liver, and spleen, which 
becomes irksome after large and heavy meals by disturbing circula- 
tion and thereby adding to the labor of the heart, and that it does 
not contain the large mass of fat-forming elements present in the 
mixed food of healthy advanced childhood or adult age. Altogether, 
it is best to slightly underfeed the patient; thereby the action of the 
heart is facilitated, — an object which must never be lost sight of. For 
the same reason fast drinking, even of water, must be avoided, for 
its sudden absorption fills the blood-vessels too suddenly for com- 
fort, and its speedy elimination does not diminish the momentary over- 
work. This warning is of particular importance as regards iced 
liquids, which act both by their bulk and by reflex. This advice is 
by no means superfluous, either to medical men or to the sick. It 
was urged by Williams more than fifty years ago. Stokes prohibited 
the use of large quantities of soups or milk. And it has been again 

29 449 



450 



DISEASES OF THE ORGANS OF CIRCULATION 



introduced by Oertel with such impressive emphasis that thirsting 
has become almost fashionable and a craze among the fanatics. 

That stimulants, such as coffee, tea, and alcoholic beverages, must 
not form part of the regular diet in cardiac disease is self-under- 
stood. They may be required as medicinal agents, however, upon 
positive indications. 

In every form of cardiac disease absolute rest both of body and 
mind is among the very first indications. The latter is just as 
important — perhaps more so — here as in diseases of the nerves and 
nerve-centres. Fretting, worrying, crying are detrimental, and must 
be avoided. Thus, it may become necessary to take a child out of 
bed, temporarily, to gratify and quiet him ; or to change his position, 
for the recumbent position of an hypertrophied heart may cause drag- 
ging of the phrenic nerve or of the sympathetic plexus ; or to raise 
the trunk and head to relieve intracranial hyperemia and the con- 
secutive irritation of the pneumogastric nerve ; or to give a mild 
opiate or a dose of potassium bromide to insure quietude or sleep. 
The child must be permitted to select his own position ; he knows 
best where he is most comfortable; but rest he must. The diseased 
heart is in its most favorable condition when working least ; the num- 
ber of heart-beats is reduced by ten or twenty-five in the recumbent 
position. Rest is not only a curative, but a preventive agent. Many 
a life-long cardiac affection could be warded off if care were taken 
in time. We are becoming more and more aware of the frequency 
of affections of the heart muscle. Myocarditis in a chronic, subacute, 
and acute form is of very frequent occurrence. In or after every 
case of typhoid fever, scarlatina, diphtheria, or small-pox we should 
be prepared to be overtaken by some cardiac disease, either interstitial 
myocarditis or parenchymatous degeneration. Rest in bed or on the 
lounge (the former is better) will act as a preventive. It ought to 
be continued for weeks in almost every case. Like the paralysis 
consequent upon infectious diseases, which develops after weeks, 
heart disease may occur from the same cause, partly as a conse- 
quence of actual primary alterations, partly of nerve exhaustion. So 
long as the pulse becomes more rapid on exertion, or on getting 
out of bed, absolute rest is the best remedy and safeguard. In these 
cases it is not always possible to distinguish between functional de- 
bility and actual disease. Autopsies too frequently tell us of our 
mistakes. Trifling changes in size cannot be measured by percussion, 
feeble murmurs cannot always be estimated according to their exact 
value. Functional murmurs are not so frequent in the child as in 
the adolescent or the adult, and exceptional only in the infant. On 



THE HEART 45 1 

the other hand, organic cardiac diseases have a better chance to be 
cured — really cured — in the young than later. So much the greater 
is the responsibility of the medical man in cases of preventable or 
remediable cardiac disorder. Even patients suffering from the very 
worst forms are apt to feel better within a very few (hours or) 
days after being confined to bed, with strict diet and loose and com- 
fortable clothing. These cases teach us the lesson of what can be 
accomplished through the same regime in milder or incipient forms, 
by reducing the labor of the heart and at the same time of the volun- 
tary muscles, with their influence on circulation and blood-pressure, 
and by diminishing the overactivity as well of the general innervation 
as of the cardiac nerves, both exciting and inhibiting. 

It is difficult to decide to what extent exercise should take the 
place of rest in individual chronic cases. The hearts of patients are 
as little alike as are their noses and finger-tips, and their treatment 
ought to be as individual as the size and shape of their gloves. 
Neither fit everybody. Nor is the rule adopted to-day that which 
will accomplish the best end in a month or a year for the same patient. 
The heart is neither in health nor in disease a uniform body. Its 
innervation may change from minute to minute, its nutrition is de- 
pendent on sudden or gradual alterations. A heart muscle is influ- 
enced in its arterial supply, venous discharge, and lymph circulation 
not only by its own health or disease, but by the ever-changing con- 
ditions of the other organs. Thus, many of the rules given one day 
may not remain valid another. Still, after a fair time has elapsed 
since the occurrence of an acute myocarditis or endocarditis, exercise 
should be recommended. The child may get up and have his quiet 
play sitting at the table, may begin to walk on the level floor, and may 
indulge in mild gymnastic exercise. More must not be permitted 
until the mucous membranes become a little more tinged, the arteries 
fuller, the heart quite regular. The systematic rules recommended 
by Stokes and by Oertel refer more to adults, with their incipient 
fatty degeneration and chronic myocarditis, than to children. In 
these, while they bear the imprint of cardiac changes, no iron-clad 
rules hold good. Gentle exercise and long rest should alternate. 

Gentle exercise may be replaced or complemented by massage 
of the skin and the muscles, both of which are so essential for circu- 
lation and metabolism. The blood circulating in a resting muscle 
during one minute amounts to 17.5 per cent, of its weight; in a 
contracting muscle to five times as much. It is easily seen to what 
extent massage, hydrotherapeutic irritation of the whole surface, and 
excitation of the muscles by the interrupted current must do good 



452 DISEASES OF THE ORGANS OF CIRCULATION 

without an exertion of the heart muscle. The avoidance of the 
latter, while the muscles are gently exercised by " resistance move- 
ments," is the peculiarity of the Schott treatment at Nauheim. It 
is indicated in a great many cases; in others it is Oertel's climbing 
exercises. In all it is the judicious mind and common sense of the 
physician in charge of the individual case. 

The skin requires judicious attention. Exposure to cold, with 
its consecutive contraction of the cutaneous blood-vessels, overloads 
the viscera, retards circulation, and increases the labor of the heart 
muscle. A cold general bath, therefore, is dangerous (as also, in 
the atheromatous degeneration of the old) in acute carditis (where 
local application of cold to the heart region acts quite favorably) 
or in extreme muscular weakness 'of the heart. On the other hand, 
a brief cold sponge-bath or wash, with thorough friction, is an intense 
stimulant and may be used to advantage for a weak heart, unless 
the extremities be cold and the mucous membranes cyanotic. In 
these latter conditions, hot washes and frictions, with or without 
alcohol, should take its place. In the average condition of the dis- 
eased heart general hot bathing must be avoided. It overstimulates 
and paralyzes, and proves an actual danger in both acute and chronic 
cases. Newspaper readers will remember the reports of people who 
go to the hot or " Turkish" bath with their heads erect and full of their 
own therapeutical wisdom, and leave it with their feet forward. A 
warm bath, the temperature of which ought not to be over 90 
or 92 ° F., is often relished. In fact, both the talking child and the 
infant will soon tell you the exact temperature best adapted to their 
wants. In these cases actual want and comfort are identical. The 
baths, particularly the first, must be limited to a few minutes; at 
all events, they should never be continued after the slightest weakness 
of the pulse is noted. The debilitating or fatiguing effect of the bath 
must be avoided. 

The mineral springs which have obtained a reputation in the treat- 
ment of chronic heart disease, like the German Nauheim and Oeyn- 
hausen, owe their effect to the stimulating action of the salts and 
of the carbonic acid contained in them. It should be remembered, 
however, that not infrequently carbonic acid, both internally and 
externally, may cause tachycardia and arrhythmia. 

Like hot water, hot air is contraindicated in heart disease. The 
wilted forms of the little ones soon show the effects of summer heat. 
A temperature of from 65 ° to 70 ° F. and fairly dry air are best 
for them. High altitudes do not agree with cardiac disease, particu- 
larly when no compensation has facilitated the heart's action. Com- 



HEART AND BLOOD-VESSELS 453 

pensation is not complete until the hypertrophied left ventricle, having 
become so by mitral incompetency, transmits as much blood into the 
aorta as the pulmonary artery does into the lungs. Until that stage 
has been reached, the lungs are comparatively hyperaemic and subject 
to catarrh, oedema, or bleeding. In this condition, therefore, the in- 
fluence of the rarefied air of high altitudes should be avoided; as 
a rule, I recommend an altitude of not more than from one thousand 
to fifteen hundred feet to children affected with chronic endocarditis. 
In the therapeutics of the heart it is most important not to mistake 
a functional disturbance of the heart's action for the immediate result 
of heart disease. The contractions of the heart (the pulse), as to 
number and rhythm, are more frequently influenced by disorders 
of other organs or of the organic economy in general. The pulse may 
become arrhythmic from cardiac (mainly myocardial) disease, but 
also from meningitis, from neuroses (chorea, hysteria, epilepsy), 
from anaemia in convalescence after grave diseases, in chlorosis, in 
universal obesity, even in the apparently healthy; from the auto- 
infection caused by constipation or by jaundice; or from the effects 
of medicines. It is self-evident that all these different causes, and 
not their common symptom, should be treated. 

The functions of the heart and blood-vessels are best considered 
together, from a clinical point of view. Together they control the 
normal blood-pressure and circulation ; when these are disturbed, 
it is mostly (not always) the same remedies or drugs that influence at 
the same time the heart and the arteries. Such disturbances are either 
an increase or a lowering of blood-pressure, and alterations in the 
circulation which are characterized by slowness or frequency of the 
pulse. In the diseases of the young it is mostly cardiac stimulation 
that is required with a view of contracting both heart and arteries. 
Its indication is furnished by primary feebleness of the heart muscle, 
or by that which is secondary to acute or chronic inflammatory or 
infectious diseases, or meningitis; sometimes by congenital under- 
size; by impaired brain function after hemorrhages, in syncope, or 
in chronic cerebral anaemia ; in tedious convalescence ; by insufficient 
diuresis; by pulmonary oedema; by reflexly lowered blood-pressure 
in shock, in colic, or after extensive burns ; by hemorrhages ; or by 
toxic dilatation of blood-vessels caused by chloral hydrate, nitrites, 
pilocarpine, or muscarine. Angina is, fortunately, very rare, for 
acute or chronic aortitis is very uncommon. Whenever it occurs it 
may cause a neuritis of the cardiac plexus near the coronary artery 
and under the influence of peri- or (and) myocarditis. 

Blood-pressure and circulation are improved by physical means, 



454 DISEASES OF THE ORGANS OF CIRCULATION 

such as transfusion, salt-water infusion, lowering the head and raising 
the feet, ligature of the extremities, manual compression of the 
abdominal aorta, and hydrotherapy in different forms. The centres 
of the medulla and of the spinal cord are influenced by strychnine 
and ergot ; the vasomotor centres and the heart by caffeine, camphor, 
ammonium, and musk; the vasomotor centres and the peripheric 
vasomotor nerves by hydrastis; the heart by alcohol, atropine, and 
sparteine; the heart and arteries by digitalis, strophantus, adonis, 
convallaria, hellebore, and apocynum. 

Among the principal remedies employed for the purpose of re- 
ducing blood-pressure and dilating peripheric vessels are warm 
baths, or foot-baths with or without mustard, warm clothing, rest 
in bed, narcotics, such as morphine and chloral hydrate, acids and 
alkalies, and the nitrites. 

At the head of the list of heart and blood-vessel stimulants stands 
digitalis. It increases the action of the heart muscle and thereby 
increases cardiac pressure. It is indicated in all conditions of weak- 
ness of the heart muscle so long as the latter is not decomposed 
and the arteries are in their usual structural condition. Primary 
changes of the heart muscle hardly ever occur in childhood, for un- 
complicated fatty degeneration, in which digitalis is contraindicated, 
is almost unknown at an early age. Secondary parenchymatous de- 
generation is, however, a frequent occurrence in and after infectious 
diseases, such as typhoid fever, dysentery, rheumatism, scarlatina, 
diphtheria, and others. Digitalis is useless and sometimes worse 
than useless in nervous affections, such as the palpitations of Graves's 
disease, of neurasthenia, or of hysteria. In all probability the effect 
of digitalis is mostly felt at first in the left ventricle, which is 
more muscular, but in the right ventricle almost as soon. By act- 
ing on the left ventricle it regulates the general circulation and facili- 
tates aspiration of the venous blood and the circulation in the lungs 
and in the right heart. It strengthens the systole and lengthens the 
diastole. During its administration the contractions of the heart 
become more vigorous and less frequent, the arterial pulse slower 
and fuller, the urine increases in quantity, cyanosis and dyspnoea 
diminish, and dropsical symptoms gradually disappear. When large 
doses have been given for some time, accumulation of the effect takes 
place. The pulse becomes quite slow and irregular, and vomiting 
sets in. If possible, this effect should be avoided. 

For how long a time may digitalis be administered when given in 
moderate doses ? This question has often been asked and as often an- 
swered. Unfortunately, the preparations sold in the markets are of 



HEART AND BLOOD-VESSELS 455 

different strengths and vary too often ; so it is best to rely on prepa- 
rations which are not liable to spoil on one's hands. With that proviso, 
I can say, from an experience of several dozens of years, that I cannot 
agree with those who stop the administration of digitalis after a few 
days, to begin again after an intermission. Moderate doses may be 
given day after day for months without any ill effect and with great 
benefit. Nor is it necessary to alternate between cardiac stimulants 
so long as no uncomfortable effect of digitalis makes its appearance. 
Only when the patient cannot be seen for many weeks in succession, 
the practitioner may feel like alternating digitalis and strophanthus 
weekly. 

In practice we are often disappointed. The preparations are as 
various as are the firms of wholesale, or sometimes retail, manu- 
facturers or tradesmen. The United States Pharmacopoeia is, after 
all, the best stand-by of the practitioner, and its list of drugs and 
that of the National Formulary of the Pharmaceutical Association 
are sufficiently large to suit any taste. The infusion of digitalis, 
when reliable, may be given to a six-year-old child in doses of a tea- 
spoonful two or four or five times a day, the fluid extract (I have often 
expressed my predilection for " Squibb's") two or three minims daily, 
the solid extract from one-half to one grain daily (0.03 to 0.06). They 
are not equivalent, the infusion being weaker by containing the digito- 
nin, which is highly soluble in water and acts rather as an antidote to 
digitalin and digitoxin. The tincture of digitalis, when reliable (not 
fixed up by mixing a poor "fluid extract" with alcohol), ought to 
be a competent equivalent of the fluid extract, if both be made of 
the English leaf gathered in July. It has been found that when digi- 
talis, though English and gathered in midsummer, is kept, the prepa- 
rations made of it later lose in strength, so that those made nine 
months afterwards display only one-third or one-fourth of their orig- 
inal power. The main constituent is digitoxin; of it there is less in 
sunless summers, to such an extent that it varies from 0.1 to 0.62 
per cent, of the herb. Gorges (Berl. klin. Woch., August 13, 1902), 
for that reason, recommends a dialysate (made by Golaz in Saxon 
Switzerland) of digitalis purpurea and grandiflora, of which chil- 
dren of two or three years are given from two to six drops three 
times a day. Indeed, children bear digitalis and cardiac stimulants 
generally better than adults, and in comparatively larger doses. Digi- 
talin I have used a great deal. Unfortunately, the wares sold by 
that name are very unequal : they are resinoids, not alkaloids. 
I have used ten or twenty times the doses recommended in books 
and price-lists without any effect whatsoever that could be relied 



456 DISEASES OF THE ORGANS OF CIRCULATION 

on. For many years I have given it up. In urgent cases a six- 
year-old child must take from one to five minims of the fluid ex- 
tract at once. That dose may be repeated after a few hours, and 
perhaps again, until the effect is perceptible. Then it is time to 
slacken off or stop altogether. It is particularly in those cases in 
which the pulmonary circulation is obstructed, either by local pul- 
monary inflammatory processes or by cardiac incompetency, that this 
mode of proceeding is advisable (p. 431). 

The effect of digitalis is not limited to the heart; the arteries 
are also affected by it. On this account digitalis is often contra- 
indicated in senile affections of the whole vascular system. As they 
(atheromatous conditions) are not found (except in a few cases 
of the literature) in infancy and childhood, this contraindication is 
rare in early age. There is a single exception, however, to this rule, 
— viz., in abnormal congenital smallness of the arteries, which is 
not so excessively rare as may be presumed, and is a frequent cause 
of life-long migraine, neurasthenia, hysteria, and chlorosis. In these 
conditions, thus caused, digitalis is not so well tolerated when given 
by itself. It acts better when combined with a nitrite. 

In those cases in which the effect of digitalis appears to be re- 
tarded, or the practitioner has " reason to doubt the qualities of his 
drug," another one may be substituted for it or combined with it. 
I plead for occasional combinations of drugs. The " simple prescrip- 
tion" flag of the " one drug only" fanatics waves over a childish affec- 
tation. They forget that they are prescribing half a dozen different 
constituents in their " one drug" digitalis. Moreover, when the heart 
requires stimulation, we should remember that it is a composite organ ; 
the muscle, the ganglia, the pneumogastric, sympathetic, and vasomotor 
nerves are suffering simultaneously. The tincture of strophanthus 
may be taken by the same child to the daily amount of from six to 
twenty-five minims; the fluid extract of convallaria majalis in the 
same or somewhat larger doses. Again I suggest that in most cases 
it is best to ascertain the moderate dose to be administered a long 
time in succession by giving a good dose from the very beginning 
and watching its effect. Of sparteine sulphate (better than other 
preparations of scoparius) eight or ten doses are required daily, 
altogether amounting to from one-half to two and a half grains 
(0.03 to 0.15). Caffeine from two to ten grains, or sodio-caffeine 
salicylate (or benzoate) from four to fifteen grains a day, are fair 
doses, the effect of which will be pleasant in most cases. In a 
former chapter of this book (p. 70) I alluded to the subcutaneous 
use of the latter; it dissolves readily in twice its weight of water 



THE HEART. REMEDIES 



457 



and is not a local irritant; it is therefore easily employed. The 
effect of these injections is often marked. Nearly twenty years ago 
I published a case of cardiac pulmonary oedema, among others, in 
which recovery was the undoubted result of their use. There is, 
however, a positive contraindication to the use of caffeine (and 
coffee), — viz., cerebral hyperemia, either active or passive, or a 
tendency to convulsions. The same contraindication holds good for 
strychnine sulphate, which has conquered a trusted place as a cardiac 
stimulant. If there be time, it may be given internally, daily, to the 
amount of from one-sixtieth to one-twentieth of a grain (o.ooi to 
0.003) f° r many days or weeks in succession. Urgent cases require its 
subcutaneous administration. Large doses, up to one-fourth or one- 
third grain (fifteen or twenty milligrammes), may be given to a 
child of ten years, in emergencies of collapse and sepsis, in a day, 
but such doses must not be continued, except in thorough sepsis. 
Sodio-theobromine salicylate has been introduced (as " diuretin") by 
G. See. It is a diuretic rather than a cardiac stimulant, and, unlike 
the former, is often found wanting. It appears to act principally 
on the epithelia of the uriniferous tubes. Calomel in small doses is 
certainly a cardiac sedative, and, as it is surely a diuretic, it is 
entitled to the many praises bestowed on it by the older rather than 
by modern physicians. Salines owe their effect upon the heart mainly 
to their action on the digestive and the urinary organs, with the 
exception of the bromides and iodides, the former of which act as 
sedatives, and thus save labor and soothe irritation. Potassium 
iodide has a more direct effect. It dilates arteries, diminishes arterial 
tension, and aids elimination through the bronchial mucous mem- 
branes and the kidneys. Obstructions of the pulmonary circulation 
depending on the heart are its appropriate indication. Sclerosis of the 
coronary arteries is not, or hardly ever, found in the young; there- 
fore this is an indication exclusively belonging to advanced age. 
A child of six years may readily take from five to twenty grains 
(0.3 to 1.25) a day, in three or four doses, in plenty of water, after 
meals. It need not often be interrupted because of the gastric symp- 
toms produced. The nitrites and their preparations play an important 
part in lowering blood-pressure. They dilate blood-vessels by para- 
lyzing the vasomotor centres (not the central nervous system), mainly 
the peripheric vessels. Large doses transform haemoglobin into 
methaemoglobin and thereby cause cyanosis, dyspnoea, and sometimes 
methsemoglobinuria. Amyl nitrite may be inhaled in drop doses ; 
nitroglycerin (trinitrite, glonoin) is given in doses of from one-five- 
hundredth to one-two-hundred-and-fiftieth grain (one-eighth to one- 



458 DISEASES OF THE ORGANS OF CIRCULATION 

fourth milligramme) in solution. The spiritus glonoini of the United 
States Pharmacopoeia contains one-one-hundredth grain in one drop. 
The effect of sodium nitrite, from one to four grains (0.06 to 0.25) a 
day, in solution or in powder, is milder but more permanent. Sweet 
spirit of nitre is of an unequal composition ; its action on the kidneys 
is more pronounced than that on the circulation in general. 

There are occasional cases in which the secondary compensation 
required by mitral incompetency is not fully established, and serious 
disturbances of the circulation arise therefrom. The dangerous symp- 
toms may be cyanosis and pulmonary (or) and cerebral oedema. 
There are, besides, stupor or convulsions, dyspnoea, dilated veins, 
cold extremities, and a small and intermitting pulse. It is in these 
cases that a few of the above-mentioned large doses of digitalis may 
do good; here it is that wavering and indecision become criminal. 
Whenever digitalis does not have any effect, a venesection may. Our 
ancestors were less pusillanimous. Maybe they overdid bleeding, but 
in an urgent case they did not fail to open a vein. I know that I have 
several times saved the lives of children (and adults) by opening a 
vein quickly. 

Chronic (and sometimes the final termination of acute) cardiac 
diseases may lead to heart-failure. In such cases stimulants are indi- 
cated. Alcohol must not be given by itself and in large doses in 
cerebral hyperaemia of any kind. A child of six years may take from 
three to twenty grains (0.2 to 1.25) of camphor internally; subcu- 
taneously, a solution of one part in five of sweet almond oil should 
be used, and from five to fifteen drops injected repeatedly. Ether 
may be given, in doses of from three to ten drops, in alcohol and 
water, and ammonium carbonate, in frequently repeated doses of 
from one-half to two grains (0.03 to 0.125), in anise-seed water or 
in milk. Musk internally, strychnine subcutaneously, may be re- 
quired. The more urgent the case appears to be the greater is the 
indication for combining several of these remedies. 

Myocarditis. — Though myocarditis, both acute and chronic, is far 
from being so common in the child as in the adult, it is nevertheless 
not infrequent ; it is, indeed, remarkable how often it is not diag- 
nosticated, or how little its occurrence is appreciated. Its symptoms 
are, it is true, sometimes very few. It need not be universal; in 
many instances the lesions are local only, in many others very 
marked, so as to lead to segmentation and fragmentation of the fibres 
(Hektoen in Amer. Jour. Med. ScL, November, 1897). The dis- 
ease is met with either in connection with endocarditis, pericarditis, 
very often with rheumatism, etc., or is quite frequently uncompli- 



MYOCARDITIS 459 

cated. Then it is parenchymatous, and the result of the toxic in- 
fluence of infectious fevers (diphtheria, influenza, typhoid, dysen- 
tery, etc.). 

In its treatment muscle stimulants must not be given. Digitalis 
is contraindicated. The recommendation of Hefren, to administer 
ergot, I cannot approve of, for by its action on the muscular fibres 
it increases vascular pressure, and thereby secondarily the labor of 
the inflamed heart muscle. Whatever relieves this temporarily is wel- 
come. Therefore, potassium or sodium iodide combined with a bro- 
mide will act favorably. Here is also the place for morphine, either 
in large doses at long intervals or in small doses more frequently 
administered, together with ice to the chest. During attacks of col- 
lapse, or during weakness or prostration, ether, camphor, and alcohol 
should be given, either internally or in an urgent case subcutaneously. 
A dose of calomel will relieve the bowels. Enemata for the same 
purpose daily, for regular evacuations are the best regulators of intra- 
abdominal circulation. In chronic cases iron may safely be given 
with the iodide; not in acute ones, which are injured by it through 
the increase of vascular irritation. Absolute rest, both physical and 
mental, is essential. That is why Oertel's and Schott's teaching of 
systematic exercise should be followed with great care only, even in 
chronic cases. The extremities should be kept warm (stockings) and 
ice-bags or wet cloths applied to the heart. Derivation by extensive 
mustard-plasters and by hot foot-baths taken in a semi-recumbent 
position should be tried. A very small pulse demands nitrites. The 
usual cardiac stimulants, such as digitalis, strychnine, etc., are contra- 
indicated, particularly in cases of arrhythmia or gallop rhythm when 
referable to myocardial weakness. 

Acute dilatation of the heart is now and then encountered after 
the parenchymatous changes of the heart muscle following infectious 
diseases. Forchheimer (Festschrift) studied it in connection with 
influenza and its etiology as myocardial and nervous, both the muscle 
and the nerve degenerating under the influence of a toxin. In chil- 
dren the myocardial insufficiency is the cause of the dilatation, rarely 
vice versa, and the latter should be met with absolute rest extending 
over weeks or months, warm bathing, iodides and nitrites, and opi- 
ates.* Recovery is much impeded by concomitant pericardial adhe- 
sion. 



* F. Forchheimer quotes Charles West, who observed, forty years ago, in 
influenza a combination of symptoms, of which dyspnoea was the principal one, 
disappearing in two or three days, followed by " extreme depression, cool, 



460 DISEASES OF THE ORGANS OF CIRCULATION 

Endocarditis. — That it is " never primary" is a mistake shown by 
Henry Hun in Festschrift. " Our forefathers knew that rheumatism 
might begin in the heart." On the other hand, heart diseases are 
rarely uncomplicated ; endo-myo-pericarditis, this complex of varieties, 
is often found in combination, and the " carditis" of our predecessors 
was a good diagnosis based on truth. The treatment of this disease 
is more promising in the child than in the adult, for entire recovery 
is more frequent in early life than later ; but it is important that the 
diagnosis should be made early. In order not to be taken unawares, 
we ought to remember that many a systolic murmur that is mistaken 
for endocardial is myocardial, and that endocarditis may be present 
without, at least for some time, exhibiting a murmur; there are, 
indeed, cases which run their full course without a murmur. ( This 
is eminently so in ulcerous endocarditis (fever irregular, murmur 
changing, sometimes quite absent, symptoms (sometimes fulminant) 
— Henry L. Eisner in Festschrift — of malaria, tendency to emboli 
not infrequent after gonorrhoea, and then not quite so bad prog- 
nostically as is suggested by S. S. Adams in Festschrift). On the 
other hand, it is also necessary to remember that functional mur- 
murs are not so common in the child, particularly in the infant, as 
they are in the adult. Thus, every murmur — though there be no 
hypertrophy developed as yet — should be suspected of being de- 
pendent on organic disease. This may also be surmised in most 
cases of acute chorea, which sometimes precedes and ushers in, instead 
of following, endocarditis; and in every case of articular rheuma- 
tism, the symptoms of which have been described in a former chapter 
of this book as sometimes so slight as easily to be overlooked (p. 
251). Acute endocarditis is also common as a sequela of the chronic 
form and as part of septico-pysemia. It is not uncommon as the 
result of acute and chronic nephritis, and of infectious diseases, such 
as scarlatina, measles, typhoid fever, variola, tuberculosis, and car- 
cinosis, and is frequently complicated — mostly through the in- 
tercession of pericarditis — with pneumonia and pleurisy, also with 
perihepatitis, perisplenitis, and generalized erythema. Frequent and 
careful examination, therefore, during the existence of such ailments, 
while it facilitates an exact and complete diagnosis, suggests the 
best method of prophylaxis. Most of the cases of endocarditis we 

moist skin, a very feeble pulse, and labored respiration. ... In this condition 
the children, though quite conscious when roused, lay generally dozing, while, 
though the somewhat livid hue of the lips and surface seemed to imply the 
existence of some serious mischief in the lungs, there was nothing to be heard 
but a large moist rale." 



ENDOCARDITIS 461 

meet with in children being due to acute rheumatism, every case 
of the latter, though ever so slight, must be watched, put to bed, and 
treated with sodium salicylate, which may be given a long time after 
apparent recovery, or resumed with every new attack. Almost every 
form of " growing pain" ought to be so treated, and in no case of 
infectious disease must the patient be permitted to leave the bed 
before much of his previous strength has been restored. 

The special treatment of acute endocarditis requires absolute rest 
in bed, a dose of calomel sufficient to open the bowels, and regular 
discharges through the course of the disease by means of enemata 
rather than of purgatives. Frequent but small meals, and articles 
of food as suggested above. If thirst be great, drinking should be 
permitted often rather than much at a time. No alcohol in the begin- 
ning. Depletion by leeches is rarely indicated, and then only when 
there is a serious complication with painful pleurisy. In rheumatic 
endocarditis depletion is not tolerated. For severe pain which de- 
pends on pleural complication the subcutaneous injection of a few 
drops of Magendie's solution of morphine is preferable. Dry or 
wet cupping will sometimes relieve in such cases ; other derivants, 
such as sinapisms, will often suffice. Vesicatories I do not advise 
in an acute case, the patient having enough to suffer from nature's 
infliction. Ice applied in a bag, which must not be too heavy, or 
ice-water cloths well wrung out, are beneficial in most cases, rheu- 
matic or other. The head and trunk must be raised so as to make 
the patient as comfortable as possible. Blue ointment has been recom- 
mended over the heart and other places, but I cannot say that I have 
reason to advise it. Strong diuretics, such as act by increasing blood- 
pressure, must not be given ; mild salines will answer best ; a small 
dose of calomel may be given from time to time. According to the 
indications noted above, potassium iodide, with or without an opiate, 
will answer best, in doses of from fifteen to twenty-five grains (1.0 
to 1.75) daily, for a child of six years. An opiate at night secures 
rest; potassium bromide may be given through the day. If the case 
be rheumatic, as it mostly is, sodium salicylate, from fifteen to thirty 
grains (1.0 to 2.0) daily, will be tolerated and found serviceable. 
Phenacetin may take its place sometimes, in daily doses, all told, of 
from five to ten grains (0.3 to 0.6). It acts as a febrifuge, an anti- 
rheumatic, and a sedative at the same time, better than quinine, a dose 
of which may, however, answer well now and then, particularly 
during remission. Antipyrin rarely, acetanilid ( " antif ebrin" of the 
trade) never. Aspirin (soluble in alkalies, therefore not affected 
by the stomach) may be given in endocarditis when it is, as usual, 



462 DISEASES OF THE ORGANS OF CIRCULATION 

rheumatic, in three daily doses of from eight to fifteen grains (0.5 
to 1.0) each. Serious attacks of dyspncea are best relieved by mor- 
phine, either internally or subcutaneously, or by lead and opium. 
Drastics will seldom be required and seldom answer the purpose. The 
nitrites may be tried, though they have not served me so well, or 
so often, as I formerly thought I had reason to expect ; they act best 
when the pulse is dangerously small. When cachexia and debility are 
prominent symptoms, tonics and stimulants are indicated early. In 
bad septic cases chloride of iron may be given at an earlier period. 
When streptococci are found in the blood, the antistreptococcus serum 
(Marmorek) may be injected in repeated doses of from five to ten 
cubic centimetres daily. Crede's ointment should be used at the 
same time, fifteen grains once or twice a day; subcutaneous injec- 
tions of yeast and of nuclein have been recommended. Among the 
stimulants, I think highly of camphor and ammonium. Among the 
direct cardiac stimulants enumerated above, digitalis ought to be 
given only after the acute changes in the muscular tissue of the heart 
have been repaired. (There is hardly a case of endocarditis unac- 
companied by myocarditis.) 

It is here that the experience and tact of the practitioner must 
decide an important point. In the further evolution of the case, digi- 
talis with quinine, digitalis with belladonna, digitalis with strychnine, 
or with a bromide, or with an iodide, together with stimulation of 
the peripheric circulation by friction, either dry or with alcohol or 
hot or cold water, find their own indications. 

The hygienic treatment of chronic endocarditis has been disposed 
of in former remarks. The medicinal agents of most importance are 
digitalis and iron. Constipation and overexertion must be avoided. 
In connection with the latter, the education and training of the child 
should be so guided as to prepare him for his future trade, busi- 
ness, or vocation. As endocarditis terminates so often in valvular 
disorders with consecutive hypertrophy, his future life ought not 
to be exposed, if avoidable, to great excitements or hard physical 
labor. A child so affected must not take coffee, tea, or alcohol in 
any shape as an article of diet. He must not be trained to become 
a military man, a pugilist, or a medical practitioner. 

The management of valvular changes resulting from endocar- 
ditis is more successful in childhood than in the adult. Compensation 
is brought about by consecutive hypertrophy ; thus it is facilitated, 
about puberty, by the rapid growth of the heart at that period of 
life, and particularly by the increase in size of the aorta and also of 
the arteries in general, thereby easing the circulation. Besides, purely 



PERICARDITIS 463 

vascular disease, which is so common in the adult, is a rare exception 
in the child. Moderate exercise contributes its share in increasing 
the growth of muscular tissue of all kinds, and should be recom- 
mended, according to Beneke,* as also in undersize of the heart. 

Pericarditis. — The pericardium is more accessible to the influence 
of cold applications than the heart. They generally act well; but 
we must be prepared to meet with doubtful or no success in many 
cases, for pericarditis is but rarely a primary or uncomplicated dis- 
ease; indeed, it is more frequently fatal on account of its compli- 
cations than of effusion. Myocardial changes (fatty degeneration 
mostly in the adult), acute oedema or acute inflammation of the myo- 
cardium in acute articular rheumatism, chronic interstitial myocar- 
ditis, or tubercle, or syphilitic gumma, or complications with puru- 
lent mediastinitis or pleuritis, are not uncommon. In pneumonia, 
pleuritis, and scarlatina pericarditis is not unusual; in rheumatism 
frequent. The internal treatment of pericarditis is, therefore, in part 
directed by the complications. Digitalis is indicated mainly in cases 
which are rather complicated ; strophanthus, convallaria, and potas- 
sium iodide may take its place or be combined with it, according to 
the suggestions made above. Morphine is demanded in most cases, 
if only to give rest for the night. The fever may require phenacetin, 
aspirin, sodium salicylate, or (during a remission) quinine. After 
the fever has disappeared, or while it is waning, absorption of the 
effusion may be promoted by caffeine, sparteine, diuretin, iodides, and 
a vesicatory over the heart. Effusion into the pericardium is not often 
so copious as to produce suffocation, but I am afraid that puncture 
of the pericardium to relieve the fatal pressure is not made so often 
as it ought to be. Fortunately, errors in the diagnosis are not very 
easily made ; still, they do occur, for I have been called to perform 
paracentesis of the pericardium where there was some pericarditis, 
more hypertrophy of the heart, and much pleuritis. The operation 



* From birth to the seventh year the volume of the heart increases from 
twenty-three to one hundred cubic centimetres, by no means in proportion to 
the weight of the body. Still, this increase is very much greater than that of 
the lumen of the arteries when compared with the length of the body. The 
pulmonary artery is wider than the aorta until puberty; afterwards they are 
equal or the aorta becomes larger. The subclavian arteries and the common 
carotids are very wide compared with the length of the body (thereby causing 
physiological and pathological congestions of the cranium and its contents). 
Between seven and fifteen years the volume of the heart is from one hundred 
and thirty to one hundred and forty cubic centimetres ; at that time the large 
arteries increase in absolute width. 



464 DISEASES OF THE ORGANS OF CIRCULATION 

is not difficult, the liquid being so copious as to give the heart ample 
space to recede in a semi-recumbent position. The aspiration should 
be made in the left mammillary line, in the sixth intercostal space. In 
the same neighborhood, at the upper margin of the fifth or sixth rib, 
the incision is made to remove pus, and irrigations may be made 
afterwards. Drainage has also been established in such cases. If 
at the same time there be pus in ,the pleural cavity, it may become 
necessary to select another spot for the pericardial operation. A. 
Fraenkel recommended it on the right side of the sternum. The 
heart has been punctured during the aspiration without evil result ; but 
I am not prepared to say, even with Biedert, that " the puncturing 
of the heart is not connected with any danger." 

Hydro pericardium, no matter from what cause, must be treated 
on the same principles as those which are valid for hydrothorax. 

Syphilis of the pericardium and of the heart, if diagnosticated 
or suspected, require their own specific treatment. 

Neuroses of the heart are not so frequent in the child as in the 
adult. The diaphragm, on account of its higher location, may annoy 
the heart in tympanites; undue motility (ptosis) of the heart may 
be congenital ; solidification of a t lung may render posture on the 
opposite side difficult and cause tachycardia or arrhythmia; early 
chlorosis or Graves's disease, alcoholism, the use of coffee or tea, mas- 
turbation, and early neurasthenia, often on an hereditary basis, may 
cause — mostly about the time of puberty — all the symptoms of slow, 
fast, or irregular heart's action. The treatment should meet the 
causes : cold water washing and bathing, cold applications to the 
heart, moderate gymnastics, no sedentary life, little schooling in the 
usual meaning of the word, codeine one dose for the night, sodium 
bromide or monobromated camphor in a few doses daily, enema daily, 
a purgative occasionally, physical and mental hygiene. 

Congenital anomalies of the heart claim attention from the mo- 
ment of birth. The newly-born candidate for cyanosis is liable to 
suffer from asphyxia, the rules for the treatment of which need no 
repetition here. When the troubles, being the result either of em- 
bryonic arrests of development or of fcetal inflammations, prove 
incurable, almost the only thing to be done for the little sufferers 
is to protect them as much as possible. If they be so unfortunate 
as to grow up, exercise should be avoided, — indeed, is avoided. Al- 
cohol is indicated in conditions of collapse only; no blood must 
ever be taken; laxatives should be sparingly given if at all. The 
temperature in which the little waifs are to live ought to be equable, 
moderately warm, their wearing apparel warm and comfortable. 



NEUROSES. ANOMALIES 465 

Congestive disorders which would require the use of cold in other- 
wise healthy children must mostly do without it, as the patients 
seldom bear it. Mild vegetable acids are coveted by many. Only 
those who appear to develop hypertrophy of the heart should take 
digitalis or strophanthus, provided their effect on the arteries need 
not be feared. Small doses of an opiate will often relieve their dis- 
comfort and dyspnoea. The combination of digitalis with iodides, 
administered for months in succession, gave relief in a number of 
cases in which the patients lived four years or more. 

There are anomalies of the infant heart which are congenital, 
or nearly so, and still not comparable in dignity to arrests of devel- 
opment. Rheumatism, scarlatina (rarely), or inflammations of some 
intrathoracic viscus, when contracted in early life, may result in 
cardiac complications. They are on the left side of the heart (while 
foetal endocarditis affects the right half pre-eminently). Hcematoma 
at the free margin of the mitral valve is formed immediately, or soon 
after birth, below the endocardium. It is liable to disappear, and 
with it, by recovery, or by compensation, or by increased frequency 
of the cardiac movements (by which the blood- wave becomes smaller 
and the valve excursion shorter), the systolic mitral murmur caused by 
it (like that which is caused by rheumatic endocarditis) ; but excres- 
cences, hard noduli (Cruveilhier), cicatrization, and insufficiency of 
the mitral valve may persist (Luschka, Virch. Arch., vol. xi.). The 
latter is easily diagnosticated and requires the usual treatment of 
acquired chronic endocarditis. As blood-nodules on the cardiac valves, 
Berti (last in Arch. f. Kinderheilk., vol. xxxi., 1901) describes what 
he takes to be, not hemorrhages, but ectasias and cysts and evolution 
processes of the valvular tissue with disappearance of the vascular 
net. Treatment as above, if any. 

The ductus arteriosus Botalli becomes nearly obliterated within 
two weeks, entirely within three months, by the aspiration of its 
blood into the newly opened lungs, by its being bent by the traction 
of the lungs, by the proliferation of the spindle-shaped cells of the 
tunica media, and finally by thrombosis. Theo. Escherich (Fest- 
schrift) describes, in cases of patency of the duct, sudden attacks 
of shallow or absent respiration, cyanosis, bulging eyes, swelled lips, 
slow heart action, and tonic contractions of the extremities. His 
treatment consists in B. Schultze's method of treating asphyxia (p. 
83). It is to be repeated many times daily, without much exertion, 
just enough to keep the lungs acting. 

Ptosis of the heart (dislocation downward) has been observed 
with epigastric pulsation as the result of weakness of the connective 

30 



4 66 DISEASES OF THE ORGANS OF CIRCULATION 

tissue of the great vessels which sustain the heart. Varicosities and 
sclerosis were noticed as consequences. Possibly a proper epigastric 
support may have a good effect. Four cases of Feranini (Centralbl. 
f. inn. Med., January 6, 1899) were complicated with mitral stenosis, 
small size and asymmetry of the cranium, feeble bones, stunted growth, 
and deformed chest and extremities; once with mental weakness. 

Congenital under size of the heart does not appear to be so fre- 
quent as that of the arteries. Indeed, in many cases of undersized 
arteries it was found of normal size, or somewhat larger. In the 
latter case the heart was not always hypertrophic; on the contrary, 
in most instances there was some fatty degeneration of the flabby 
muscle. Like every small organ, the small heart may be built up 
by moderate and persistent gymnastic exercise, a small dose of 
strychnine given three times a day for weeks or months in suc- 
cession, cold washing and friction, and an altitude of from one thou- 
sand to fifteen hundred feet. A certain amount of muscular growth 
will probably result from it; it is quite welcome, for the labor of 
the heart requires either an organ of sufficient size or one of unusual 
strength. 

Neoplasms of the heart (carcinoma, sarcoma, fibroma, myoma, 
lipoma, myxoma, tubercle, echinococcus, cysticercus, and syphiloma) 
are rare in early life, the last named more frequent than the rest, and 
the only one that so far can be reached by (antisyphilitic) treatment. 

2. The Blood-Vessels. 
The structure of the blood-vessels is sometimes very defective, 
the walls being thin, fragile, and pervious. In such cases hemorrhage, 
small or copious, is a frequent symptom. The frequency of hemor- 
rhages in the newly-born, leading, when in the cranial cavity, to 
asphyxia, convulsions, idiocy, or early death, is, among other reasons, 
caused by the thinness of the vessel-walls, whose tissue has not yet 
quite evolved from its embryonal condition. This, or a similar condi- 
tion, may continue for life. This hypoplastic state, however, is not, of 
necessity, general : it may be local. The early nose-bleedings of some, 
though they have no heart disease, and the congenital tendency to 
aneurism, mostly in places where the elastic tissue, either from arrest 
of local development or by microbic destruction, is either scanty or 
absent (usually at the origin of branches, Eppinger), prove the occa- 
sional occurrence of these circumscribed and local defects.* A uniform 

* A. Jacobi, Extracranial Aneurism in Early Life (Trans. Tenth Internat. 
Med. Cong., Berlin, 1891). 



BLOOD-VESSELS 467 

thinness of many or all of the arteries, however, is most likely to 
be complicated with narrowness, which has been studied by Virchow, 
See, and others in its relation to incurable chlorosis, palpitation, and 
cardiac asthma. That thinness which predisposes to fatty degenera- 
tion of the intima and media, to sclerosis of the adventitia, to athe- 
romatous endarteritis, and to the formation of aneurism at an early 
age has not been made the subject of active treatment, so far as I 
know, except by myself. I feel convinced that the administration of 
phosphorus, — not phosphates of any kind, — with its stimulant effect 
on the growth of connective tissue in general, has rendered me good 
service in habitual tendency to cutaneous, mucous, and internal hem- 
orrhages. Hcemophilia of moderate degrees appeared to improve 
under its use, and the children to be safer and better developed. The 
dose for a child of three years should be from one-fiftieth to one- 
thirtieth of a grain (0.001 to 0.002) daily; that means from two to 
three minims of the oleum phosphoratum, or from one to one and a 
half teaspoonfuls daily of the elixir phosphori (United States Phar- 
macopoeia of 1890).* 

Atheromatous degeneration of arteries, large and small, in babies, 
children, and adolescents is rare, but cases are from time to time 
reported. In another part of this book I have spoken of the recom- 
mendation of lactic acid in these conditions. Syphilitic vascular 
changes require their specific treatment. Tuberculosis of blood- 
vessels, mainly small arteries, has been known a long time. Bacilli 
enter through the lymph and the blood circulation, are frequently 
perivascular first, and find their way into the intima. 

Thrombosis of veins in general, and of the sinuses of the dura 
mater in particular, is the result of retardation of the (general or) 
local circulation and of coagulation of blood by marasmus from what- 
ever cause: rapid elimination of water (cholera infantum), debility 
of the heart, pressure on veins, or inflammation in the neighborhood 
(for instance, caries of the petrous bone). In the same way throm- 



* The unreliability of the percentage of phosphorus when dissolved in oil, 
and particularly in cod-liver oil, is the cause of the ill success in the hands 
of observers and of the clouds of European magazine articles that rain down 
on the profession. If they would only use, now and then, the preparations of 
the U. S. Pharmacopoeia! Binz, who favors phosphorus therapeutics (mainly 
in rhachitis), recommends a method to determine the percentage of phos- 
phorus in oil solutions (Centralbl. f. inn. Med., November 14, 1902). A phos- 
phorus solution which is invisible in the dark becomes visible when warmed. 
Such solutions as contain little phosphorus require a relatively high tempera- 
ture for that end. 



468 DISEASES OF THE ORGANS OF CIRCULATION 

bosis of the femoral vein may be caused by peritonitis or by a pelvic 
tumor (or by fractures not set). In the cranium the right trans- 
verse sinus is most frequently affected, but quite often also the 
inferior petrous, cavernous, and longitudinal sinuses. Such throm- 
boses cause hyperemia, cedema, or extravasations ; it is by their symp- 
toms that the diagnosis is made. The treatment must be preventive 
in order to be successful. Early attention to the ear and mastoid 
process, treatment of diarrhoea before inspissation of the blood 
and heart-failure take place, timely stimulating and roborant treat- 
ment, and not pro re nata, — that is, when it is just a little too 
late, — are the best preventives. The subcutaneous injection of large 
quantities of warm sterilized water, with sodium chloride (iooo 
to 7), is capable of preventing the inspissation of the blood which 
results from acute and copious diarrhoea, and often proves life- 
saving. 

Welch refers a number of venous thromboses to cardiac diseases 
(Festschrift), mainly to advanced mitral affection with failing com- 
pensation, tricuspid insufficiency, and pulmonary infarctions. Flex- 
ner asserts the frequency of terminal bacteric infections in heart 
diseases. All this preaches the sermon of preventive treatment 
(and curative so far as possible) of cardiac and of infectious dis- 
orders. 

Congenital local dilatations of blood-vessels, capillaries, smallest 
veins, and smallest arteries, together with an increase of their num- 
ber, and mostly with incompetent structure, are known by the names 
n&vus, telangiectasia, angioma. Their color depends on the nature 
of the blood-vessels composing the anomaly, also on their distance 
from the surface, their size on the extension of the morbid process, 
and their size and consistency on the admixture of connective tissue. 
They are found in all sorts of tissues and organs, mostly on or below 
the surface of the body. In the subcutaneous tissue, when mixed with 
much connective tissue, they are liable, after having remained un- 
changed for many years, to undergo sarcomatous degeneration. 
Therefore, and because of their tendency to rapid growth in every 
direction, with increasing deformity and possible danger from hem- 
orrhage, the early removal of all those which do not exhibit from 
the beginning a tendency to fade and finally disappear is indicated. 
The methods followed to obtain that end are very numerous. Vac- 
cination over a naevus will generally destroy it, but may do so but 
partially, and will leave a bad scar. Plasters of tartar emetic and 
of Vienna paste cannot be controlled to such an extent as to de- 
stroy the growth only. Injections of perchloride or subsulphate 



NyEVUS. ANGIOMA 469 

of iron are known to have given rise to extensive thrombosis, gan- 
grene, and death; injections of alcohol have been tried, but have 
not, I think, reached farther than the ear of the medical public. 
Corrosive sublimate in collodion (1 to 8) is an excellent caustic 
where the naevus is not extensive, particularly on the head; it rarely 
requires more than a single application. Fuming nitric acid is per- 
haps the best of all local applications ; the pain is but temporary, and 
the effect circumscribed and fairly thorough. But it ought to be used 
for superficial nsevi only, and even then requires repetition in a 
number of instances. Excision is a good method if the operation 
can be performed in a short time and all the morbid parts can 
safely be removed without loss of too much blood. The ligation of 
angiomatous tumors is indicated where they can be entirely grasped 
either without or with the aid of needles run through their base ; but 
time is required for them to fall off finally, and the wound demands 
careful and persistent antiseptic treatment until the danger from local 
infection has passed and a smooth scar has been perfected. Electroly- 
sis has been praised very highly, particularly in the treatment of the 
extensive wine-marks. Still, personally, I never saw a satisfactory 
result in these cases. There remained always speckled, whitish scars 
of small size alternating with the original discoloration, — a result 
which I should not claim as an improvement upon the original condi- 
tion. The actual cautery is the most satisfactory of all our remedies ; 
very few will at present use it in any other shape than that of the 
galvano- or the thermo-cautery. The heat should not be excessive: 
white heat destroys blood-vessels too rapidly to permit of simulta- 
neous coagulation of the blood, and produces hemorrhages. Dull-red 
heat will accomplish a cure. A momentary application suffices for a 
superficial naevus; its action can always be controlled and strictly 
localized, and the formation of the scurf secures against surface 
infection. Nor are large angiomata inaccessible to it. When these 
are to be destroyed, it is best not to attempt too much at first. It 
is unnecessary to destroy everything; long after the direct effect 
has passed away, coagulation in the blood-vessels and slowly pro- 
gressing cicatrization result in the gradual lessening of the swelling. 
When the tumor ceases to diminish in size, the operation is repeated, 
sometimes after many weeks or even months. The cautery is 
then introduced into the very spot at which the previous application 
was made. In this way the cicatrix remains localized. As a gen- 
eral rule, a cicatrix following the application of the actual cautery 
is smooth and becomes more so and less perceptible from year to 
year. 



470 DISEASES OF THE ORGANS OF CIRCULATION 

3. The Lymph-Vessels. 

Lymphangioma is the dilatation of lymph-vessels, localized or 
multiple, with or without proliferation, extending from the walls of 
the lymph-vessels. Careless operation with the knife may lead to 
lymphorrhcea ; I removed several with the actual cautery. When 
in the skin, multiple, and connected with hypertrophy and oedema 
of the cutis and subcutaneous tissue, either localized (neck, shoulder, 
dorsum, extremities) or diffuse, it is called elephantiasis. It may 
be removed when not so extensive as even to preclude, after removal, 
skin-grafting to replace the defect. 

Of chyluria (lymphorrhcea into the urinary organs), such as is 
frequent in tropical regions under the influence of filaria sanguinis, 
and observed by Bouchut in an hysterical girl of fifteen (no cause 
known), I have seen one case in a child of eleven years. Kamienski 
had a case of chylous ascites in a baby of five weeks. Paracentesis 
appeared to be harmful, recovery was spontaneous (Jahrb. f. Kind., 
vol. xlL). 

Cystic lymphangioma (hygroma, on the neck and in the axilla) 
is unilocular or multilocular, slightly movable, fluctuating, and not 
compressible, because there is no longer any open communication with 
the rest of the lymph-system. On the neck it may be mistaken for the 
hygroma resulting from a partially patent and endwise obstructed 
branchial arch. Total extirpation is the preferable operation if it 
can be done. Puncture and subsequent irritation by injection of alco- 
hol, or Lugol's solution, or diluted carbolic acid (from three to five 
per cent.) may require repetition in multinuclear cases. That is why 
incision of the cavities and subsequent iodoform drainage should be 
preferred. Occasional complication with a malignant tumor impairs 
the prognosis. 



XI 

Diseases of the Skin 

Burns. — Burns of the first degree rarely require more than cool- 
ing applications and rest, both general and local, water, lead wash 
of different strengths, oil, and cotton. Persistent cold applications 
are not tolerated. When large blisters have been formed, the epider- 
mis should be removed and the sore surface irrigated with an anti- 
septic solution or an aseptic sterilized saline solution (6 to iooo) 
and thoroughly dusted with bismuth subcarbonate or dermatol. An 
aseptic dressing then applied may remain eight or ten days ; after 
that time the sores will generally be found healed. Individual cases 
and opportunities may require different methods. The time-honored 
application of equal parts of lime-water and oleum lini, to which 
a twentieth of a per cent, of thymol may be added, is still much 
favored. The burn should then be thickly covered with aseptic 
gauze. After this application is removed, a fine powder of bismuth 
subcarbonate should be spread over the wound and the whole covered 
with gauze again, or an ointment containing bismuth, or bismuth 
and boracic acid, or bismuth and zinc may be employed. To thor- 
oughly guard against infection, the washing of the wound with a 
three-per-cent. solution of carbolic acid, or of salicylic acid, or of 
boracic acid (not so painful as the other two) must precede the 
application of a gauze thoroughly covered with bismuth subgallate 
finely powdered, or with a mixture of bismuth and starch, or the 
same with the addition of from one to two per cent, of salicylic acid. 
Such an application may remain undisturbed for weeks. Orthoform 
powder is soothing and fairly antiseptic. Extensive burns do well 
in the permanent warm bath. Should large defects result, trans- 
plantation may be practised afterwards ; if contractures, extension 
must be employed in time and apparatuses used for a sufficient 
period. 

The younger the patients the more liable are they to suffer from 
burns, though apparently mild. Reflex symptoms of a nervous char- 
acter are not quite so bad as the transformation of haemoglobin into 
methgemoglobin, or the toxic swelling of lymphatic glands, both or 
either of which conditions are held responsible for the excessive 
dangerousness of extensive burns. Much reaction may set in after 
a day, with high fever and convulsions. Therefore the thermometer 

471 



472 DISEASES OF THE SKIN 

ought to be consulted soon after the accident and the symptoms 
prevented or treated. Diarrhoea is not uncommon, even after moder- 
ate burns, and requires opium and the regulation of diet; collapse 
demands stimulants, either internal or subcutaneous; and sleepless- 
ness appropriate narcotics. 

Burns are more frequent than are the effects of cold, though there 
are patients who suffer from the latter annually. Common frost-bites 
are frequent, it is true, and annoying, but rarely of great importance. 
The rubbing of red, itching, and swollen parts with snow (or with 
petroleum) is quite effective in mild cases. The itching is often 
relieved by a mild tincture of iodine or by the application of a (from 
three to ten per cent.) solution of silver nitrate or of calcium chloride 
in water (i to 2 or 200), also by camphor in lanolin (1 to 10). The 
popular remedies of tallow and whiskey or, better still, the application 
of carpenter's glue to frost-bites bring relief. This may also be 
obtained by surrounding the inflamed swelling by a protecting (corn) 
plaster. Vesicles on the toes and heels, filled with blood and resulting 
in ulcerations, require the latter treatment, together with bismuth 
subgallate, naphtalin, orthoform, or cauterization with silver nitrate 
until granulations spring up, or an ointment of balsam of Pern 
with or without zinc oxide, or bismuth, or applications of a three- 
per-cent. solution of aluminum acetate, or a fuchsin one, lanolin 
eighty, vaseline twenty ointment. Gangrene of the skin or of whole 
extremities is, fortunately, rare. When it occurs it demands rational 
surgical treatment. 

Subcutaneous emphysema may be the result of fracture of ribs 
or sternum, as in the adult. Most of the cases I have seen occurred 
during inferior tracheotomy when the incision was too long, or 
during whooping-cough; a few in pulmonary abscess with adhering 
pleura. Actual treatment was never required, as absorption takes 
place within one or two weeks. 

Erythema is met with at every age of infancy and childhood, and 
depends on a number of causes. The treatment is, therefore, partly 
symptomatic, partly causal. In the newly-born, from the establish- 
ment of an unprecedented cutaneous circulation and the discontinua- 
tion of the intra-uterine amniotic pressure, the skin becomes red, 
changes to yellow (alterations of hasmatin), is subject to extensive 
peeling, and, finally, obtains its normal pink color under ordinary 
circumstances. The erythema, however, is not always uniform ; now 
and then it bears a resemblance to measles, and is attended by fever, 
but not by catarrh. As a rule, it demands no treatment except pre- 
ventive. The bath must not be hot, the temperature of the room not 



ERYTHEMA 



473 



abnormally high, the bedding not hot and oppressive. Vaseline, cold 
cream, or lanolin is useful where the redness and the tendency to 
peeling are very marked. 

In the following months erythema is a common symptom when 
the babies are exposed to pressure or friction by clothing, to the 
heat of the summer, of stoves, bedding, or bathing, to irritation by 
urine, or to the septicemic after-effects of infectious fevers, such as 
measles, angina, diphtheria, typhoid, or influenza, or after drugs like 
salol. In some of these cases desquamation is observed; it is the 
more readily a cause of mistaken diagnosis the longer it lasts and 
the greater its extent. Children of three or four years, when afflicted 
with diarrhoea and consecutive cachexia, are subject to a papular 
erythema which is mostly confined to the gluteal regions and the ex- 
tremities. Finally, thin and feeble children exhibit frequently a gen- 
eral redness, sometimes mottled, which lasts as long as does the 
sluggish circulation depending on their general condition. 

The indications for treatment in all of these varieties are furnished 
by the causes. Irritation of the surface should be avoided; the 
patient must not be exposed to abnormal temperatures, either of air 
or water, or to errors in diet; diarrhoea and emaciation must be 
arrested, and vaseline and fats used according to necessities. In 
many cases a full supply of drinking-water, which is too frequently 
withheld from the very young, corrects the evil by stimulating cuta- 
neous circulation and the tendency to perspiration, which is almost 
absent during the first month and very scanty in the second and 
third. 

Constipated and dyspeptic children are very apt to suffer from 
erythema as the result of intestinal autoinfection, sometimes to such 
an extent that the diagnosis between it and scarlatina may become 
doubtful. The difficulty grows in those cases in which the intestinal 
erythema is attended by the corresponding intestinal fever, an occur- 
rence not at all uncommon. Constipation may be congenital or 
acquired, and may lead to the same result. The diagnosis is not 
always easy for other reasons, — viz., the apparent normality of the 
stomach, which may be found dilated, the absence of diarrhoea, and 
the actual or alleged absence of flatulency. This erythema is not 
uncommon; it may last hours or many days, or may alternate with 
acute attacks of urticaria. The latter is, therefore, not always gastric 
or neurotic, either in its acute or chronic form, but may be toxic, 
and it thus shares the etiology of many cases of acne and some of 
senile pruritus. When occurring in the face exclusively, I have seen 
it mistaken for erysipelas. 



474 DISEASES OF THE SKIN 

This variety of erythema is sometimes seen mostly on the hands 
and feet, is symmetrical, and now and then, like urticaria, has vesicles 
or bullae (similar to herpes iris). When it accompanies intestinal 
autoinfection, it is usually followed by indicanuria, though perhaps 
not so regularly as in adults with intestinal disorders, and ether- 
sulphuric acids in the urine, which is liable to be very scanty and 
of high specific gravity. When in such cases it is universal or nearly 
so, that condition of the urine may now and then be utilized for the 
differential diagnosis from scarlatina, measles, or rubella. Skatol 
and indol are found in the faeces. In most cases a purgative (prefera- 
bly calomel) will bring speedy relief, but actual and lasting aid will 
only come from prolonged disinfection of the intestinal tract by naph- 
talin, salol, resorcin, oil of peppermint, small doses of calomel or 
hydrargyrum bichloride, from large enemata containing a twentieth 
of one per cent, of thymol, or from such as consist of aromatic 
infusions (mint, catnip, chamomile) exclusively, from occasional 
purgatives, and from the regulation of the diet, which must be such 
as not to cause fermentation and putrefaction. In the employment 
of the sulphites (of sodium and magnesium) I have been rather 
disappointed. The use of menthol is not to be recommended ; it can 
be swallowed in capsules only, and to atone for its local irritation it 
has no eminent virtues. As to diet, proteids, except milk, should 
be avoided; farinaceous foods (cereals) are preferable. Orange-juice 
is pleasant and useful. Hydrochloric acid in water ( i to 1500 or 2000) 
as a regular beverage for weeks. 

Erythema nodosum (p. 258) may be discussed in connection 
with this subject. It is probably an angioneurosis of infectious 
origin (rheumatism, etc.), complicated frequently with pleuritis and 
endocarditis, very much like erythema exudativam multiplex, and 
consists of large nodes, whose redness turns yellow in the course of 
the normal alterations of hsematin ; it is mostly seen on the legs, but 
also along a number of tendons from the occiput downward. It 
requires rest. When it is the result of rheumatism, sodium salicylate 
is indicated; when it depends on malaria (Moncorvo), quinine. A 
six-per-cent. solution of silver nitrate has been recommended for ex- 
ternal application. I have used with benefit, I believe, inunctions of 
oleum gaultheriae, of potassium iodide in glycerin (1 to 2 or 4), and 
of potassium iodide and lanolin ointments. 

Erythema complicated with loss of epidermis, either without ap- 
parent cause or through irritation by urine or fseces, or by fric- 
tion of the adjoining surfaces of the nates, thighs, axilke, and the 
folds of the neck, together with secretion, and even crusts, is called 



ERYTHEMA NODOSUM. INTERTRIGO. ACNE. SEBORRHCEA 



475 



intertrigo. It is mainly noticed in fat, flabby, and rhachitical babies, 
is painful and annoying, and may prove dangerous by becoming gan- 
grenous or by inviting the invasion of erysipelas or of diphtheria. 
Therefore, its treatment and cure are imperative. The diapers must 
be soft, not pinned during sleep, and frequently changed ; the babies 
must be kept scrupulously clean and bathed at least once a day. A 
seven-per-mille solution of table salt is more pleasant than water 
alone. Diarrhoea should be relieved by dieting, internal medication, 
and rectal injections. Astringent solutions (zinc sulphate, aluminum 
acetate, tannin) would be beneficial but for the difficulty of making 
regular applications ; ointments containing zinc oxide, bismuth, tan- 
nin, or lead are preferable. Fine powders of bismuth subcarbonate, 
of talcum, of amylum, or mixtures of two of them, with or without 
the addition of one or two per cent, of salicylic acid, will act satis- 
factorily. The popular lycopodium powder is not to be recommended. 
By reason of its gluing together it proves irritant, like all foreign 
bodies. 

Among the circumscribed inflammations of the skin met with in 
children, mostly of advanced age, are acne, lichen, and prurigo. 
Acne is dependent on an interrupted action of the sebaceous folli- 
cles. They begin their rapid development about the middle of intra- 
uterine life, and are large and numerous at birth, particularly over 
the nose, ears, eyebrows, and around the mouth. When obstructed, 
they exhibit in the infant no black-heads like the comedones of the 
adolescent or adult, but are white. Normally, they secrete much tal- 
low, which gives the foreheads of many babies their shining, glossy 
appearance. When this tallow accumulates and gets dry, and mixes 
with the scabs of the epidermis and foreign material, such as dust, 
etc., it forms seborrhcea of any shade of color between whitish and 
black, which is more difficult to remove because of the conservative 
superstition of the mother than because of its own obstinacy. Its 
importance and its dangers are quite local ; it interferes with the 
growth of hair and predisposes to local irritation of the scalp ; it 
ought to be removed by oil, fat, soap, hot water, and brush, and the 
subjacent hyperemia relieved by an astringent ointment. No stimu- 
lating diet. Ichthyol in solutions or in ointments has been frequently 
recommended, as in all irritations and inflammations of the skin. 

When acne has formed (in older children) the comedones ought 
to be squeezed out. For this purpose an old-fashioned watch-key 
with broad edges will prove as serviceable as most of the mechanical 
devices of instrument-makers, almost as much so as PifTard's handy 
little instrument. Frequent hot washing with green soap, or spirit 



476 DISEASES OF THE SKIN 

of soap, followed by ice-cold washing, I have found very useful; 
besides, the skin should be washed four times a day with a solution 
of corrosive sublimate in water, or in alcohol and water (i to 20 to 
2000 or 1 to 20 to 1000). 

Washing with vinegar dissolves the epidermis cells and thus aids 
in disintegrating and loosening the obnoxious material. Various 
mixtures of emplastrum and unguentum plumbi may be employed. 
After a thorough cleansing with soap, equal parts of precipitated 
sulphur, glycerin, and alcohol (to be preserved in a well-stoppered 
jar) are applied in the evening and washed off in the morning; or 
beta-naphtol 10 parts, precipitated sulphur 50 parts, lanolin or vase- 
line 25 parts, and green soap 25 parts are applied and removed by 
washing after fifteen or twenty minutes, after which the skin is 
covered with talcum or starch. Only in the very worst forms of 
acne (fortunately, rare in children) must scarifications be resorted to. 

Lichen is mostly found in its mildest form: strophulus of pin- 
head size, slightly excavated on top, around a hair. It is not particu- 
larly resistant, but is liable to return. Lichen scrofulosorum, how- 
ever, the result of living — not virulent — tubercle bacilli that give rise 
to no other symptoms, is apt to be obstinate. It is mostly met with 
in older children, is of a yellowish or red color, and forms a circle 
around a hair. It does not itch very much, but by reason of its dura- 
tion and appearance is quite annoying. Locally, warm bathing and 
frequent ablutions with vinegar and water (1 to 3 or 6) will act well. 
Antipyrin in a nightly dose will relieve itching whenever troublesome, 
and by its sudorific effect will contribute to the disintegration of 
epidermic accumulations. The general treatment of scrofula is re- 
quired on account of its causal indication. Lichen acuminatus and 
planus consist of circular nodules congregated round a pigmented 
spot, the first in rows, the second flat. Both are rare in children. 

Prurigo is found, of pin-head size and pink color, on the extensor 
side of extremities and in the gluteal region and on the abdomen. 
In its neighborhood the lymph-bodies swell, and chronic pigmenta- 
tions are frequent. The itching is terrible, intolerable, exhausting, 
and may prove fatal. Twice I saw it complicated with or depending 
on early diabetes ; in both cases it terminated only with the fatal 
cause. Inunctions of glycerin or fat and protracted warm bathing 
in water or alkaline water should be resorted to. The baths ought 
to be continued for hours, and may be allowed to last half a day. 
Vinegar will dissolve the epidermis. Pilocarpine will do well in sub- 
cutaneous injections large enough to produce perspiration. As much 
and as long as permissible it may be combined with antipyrin; and 



LICHEN. PRURIGO. FURUNCULOSIS 477 

if subcutaneous injections be found impossible, it ought to be admin- 
istered internally. Tar, sulphur, and green soap have been found 
very useful, when continued for from four to six weeks in alternation 
with warm baths. Wilkinson's ointment contains all of them (flor. 
sulphuris, ol. rusci, aa 10 parts; sapon. virid., vaselin., aa 20 parts). 
Kaposi recommends naphtol ointment (5 to 100). The addition 
of five per cent, of menthol to every ointment used will prove help- 
ful. But it should not be forgotten that the prognosis becomes more 
serious with every month or year of the duration of prurigo, and 
that general and preventive treatment demand urgent consideration. 
Most patients are stricken in their second year; thus an hereditary 
influence is to be suspected in many. Often the parents are tuber- 
cular. The urine should be examined for glucose. 

Both prurigo and lichen (also acne in the severe form — rosacea 
of adults — ) will often be benefited by ichthyol (thiol has been recom- 
mended for the same purpose, locally) in from five- to twenty-per- 
cent, ointments. It may also be given internally, when there are hard 
and irritating infiltrations, in daily doses of from five to twelve grains 
(0.3 to 0.8). Other internal medication is useless, except arsenic, 
an occasional purgative, and now and then a sedative (monobromated 
camphor at bedtime in doses of from two to six grains = 0.125 to 
0.4) ; strict avoidance of stimulants and moderate use only of meat 
are the main dietetic rules. 

Furunculosis in the very young does not often exhibit the same 
character as in adults. Both the sebaceous follicles and the perspira- 
tory glands being rather patent, there are rarely such large and hard 
indurations. It is often complicated with acne, or follows eczema, 
and may complicate scabies. It is frequently found in cachectic in- 
fants and children and after protracted diarrhoea, generally in the 
form of multiple and cold abscesses ; sometimes in connection with 
tuberculosis and glucosuria. These abscesses are liable to lead to ex- 
tensive suppurations of the connective tissue. The skin must be kept 
disinfected either by blue ointment or by corrosive sublimate in water 
(1 to 2000 or 5000). Abscesses — no matter how many — must be in- 
cised and disinfected with sublimate solution, or iodoform, or treated 
with the sharp spoon, or filled with antiseptic gauze, according to cir- 
cumstances and to sizes. Now and then these abscesses are found near 
the matrix of the nails, not multiple as in syphilis, but localized, and 
are liable to destroy the matrix unless incised and disinfected in time. 
Secondary lymphatic swellings round the neck will, when benign, 
disappear after a while. If not, they are probably tubercular, and 
if persistent, without a tendency to get smaller, ought to be enucle- 



478 DISEASES OF THE SKIN 

ated. A preventive measure is the covering up of incipient furuncles 
with some indifferent plaster (soap, belladonna; no turpentine) to 
avoid the friction of the clothing. Arsenic in small doses, but persist- 
ently given, has a favorable effect. G. Langmann speaks highly of 
the preventive and healing local effect of the galvanic current. 

One of the most common forms of dermatitis in the young is 
eczema in its different forms : the dry, not scab-forming, and very 
itchy; the small vesicular and papular, with but slight desquamation 
or the formation of thin scabs; the purulent variety, impetigo, with 
moderate crusts ; finally, the rapidly growing and pointed ecthyma 
and rupia. For, indeed, all of them are but varieties of the same 
process. It may be microbic in isolated cases, but certainly is 
not a microbic disease generally. It may be complicated, however, 
with a parasitic ailment such as scabies. A disposition is caused 
by the tendency to congestive, catarrhal, or inflammatory disorder 
such as is understood by " scrofula," not by tuberculosis ; also by 
rhachitis, chronic indigestion, and anaemia ; also by incidental fevers, 
— for instance, that of vaccinia ; indeed, it is not uncommon to date 
the first appearance of eczema back to the effect of vaccination. These 
occasional or constitutional partial causes of eczema must be considered 
as regards general and constitutional treatment. These are the cases 
apt to be benefited first by appropriate diet, then by the protracted 
use of arsenic, the hypophosphites, cod-liver oil, and iron. Still, it 
is important never to be tempted to begin such a treatment in an 
acute attack of eczema, which is more apt to be benefited by a few 
moderate closes of quinine and purgatives. 

Acute eczema is liable to run its course with a great deal of 
swelling and irritation, resembling in these respects erysipelas. It 
bears absolutely no water, and in the beginning no ointments. Pow- 
ders of amylum, or of bismuth subcarbonate, or zinc oxide, or aristol, 
pure or in different proportions, with or without the addition of one 
or three per cent, of salicylic acid, prove more efficient. After a while 
the same constituents may be used as ointments. No large surface 
of a nursling's skin should be covered with ointments at the same 
time. Still, an occasional death during the treatment of eczema 
should not be attributed to it or its treatment, but to the " lymphatic 
condition" and circumstances connected with it, and to other causes. 

Most of the cases presented for treatment are chronic, either in 
the moist, or crusty, or squamous form. Many of them are itching, 
and are apt to lead to persistent infiltration of the skin, even amount- 
ing to elephantiasis. In many of them the original local causes are 
still persistent and can and must be relieved or removed. All sorts 



ECZEMA. IMPETIGO. ECTHYMA 479 

of local irritation are found. Seborrhcea, uncleanliness, secretions 
of the nose, ear, and eye which are permitted to remain and irritate 
the neighborhood, the oral secretion from whatever cause excoriating 
the cheeks and chin, the septic piercing of the ear, the presence of 
vermin on the skin, are all frequent causes of eczema, the predisposi- 
tion to which is established on certain parts of the body where eczema 
is most common (head and face) by the large size of the carotids 
and the physiological congestion and rapid development of the head 
and all its organs. By mistaking this connection, even the physio- 
logical protrusion of the teeth has been charged with producing 
eczema. Indeed, everything causing sluggish circulation and con- 
gestion to the surface — the constipation, for instance, of fat babies, 
hot bathing, the influence of solar and stove heat — may have the 
same result. 

The effect of protracted eczema on the head is liable to be grave 
by interfering with the growth of the hair; by causing and ex- 
tending catarrh of the ear and nose, or blepharitis, conjunctivitis, 
or keratitis ; by producing open sores and thus facilitating the inva- 
sion of erysipelas and possibly of tubercle germs; by irritating and 
tumefying the numerous lymph-bodies of the neighborhood with 
the complication of hyperplasia or tuberculosis. Thus, the indica- 
tions for treatment should be considered urgent in every case of 
eczema ; the sooner it is suppressed the smaller is the number of 
complicating clangers which are direct outgrowths of what appears 
to be, in most cases, a merely local affection. 

Local as well as general hygienic and constitutional treatment — 
mostly preventive — is required. The body of the infant must be 
kept clean, but the local eczema should not be touched by water more 
than is absolutely necessary ; the reaction after the bath is liable to 
bring out a new eruption. If this be on the head, the hair should 
be cropped close. The nails must be kept short so as to prevent 
scratching as much as possible, the hands sometimes tied up, or the 
face covered. Remove thin or thick scabs by warm water, soap and 
water, warm fomentations (not on the head), oil, fat, liquor potassii 
in oil or in cod-liver oil (1 to 8 or 12). Use the comb when the scabs 
are beginning to loosen. Below them the surface is hyperaemic or 
oozing; the secretion must be wiped off and stopped as soon as 
possible. Solutions of astringents are neither so convenient nor so 
effective as ointments. The official zinc ointment will suffice in 
many cases, if fresh. Vaseline by itself is irritating. Bismuth sub- 
carbonate 5 parts, with ungt. zinci and vaselin., aa 20 parts, is a good 
combination. Such applications may be made from two to five times 



4 8o DISEASES OF THE SKIN 

a day. Hebra's ointment is thickly spread on linen and the surface 
covered with it ; layers of it may be worn for days or weeks. There 
is no harm in the extensive use of lead; I never saw or heard of a 
case of direct cutaneous absorption which stood criticism, but I have 
seen lead poisoning in a boy who scraped the lead ointment from his 
cheeks and ate it for many weeks in succession. The formulae now 
and then published in the journals are very numerous ; every thought- 
ful practitioner will make or combine his own from bismuth, zinc, 
lead, or tannin. In addition to these, I mention for inveterate 
cases and the scaly form tar (tar, alcohol, and green soap in equal 
quantities, or ol. cadinum I part, ol. oliv. I part, lanolin. 10 parts), 
hydrargyrum ammoniatum (either the official ointment (too strong) 
or a modified formula, such as zinc oxide I part, ammonium hydrate 
i part, ol. amygdal. dulc. I part, fat 10 parts), and, finally, silver 
nitrate. It is mainly in the most obstinate chronic cases of eczema — 
the crustaceous or squamous variety — that a large surface will heal 
under the influence of a solution of from three to ten or forty per cent, 
of silver nitrate, thoroughly applied. A good ointment is made of 
hydrargyrum bichloride I to 200 or 300 of lanolin, which may be 
gently rubbed in once or twice a day. 

Tar has one grave inconvenience. On skins which absorb rapidly 
it may prove dangerous to the kidneys. Nausea, vomiting, diarrhoea, 
headaches, vertigo, and a smoky or even black urine, occasionally 
with more than mere albuminuria, may be observed. The same, to 
a greater degree, must be said of carbolic acid, which may be added 
to ointments (2 or 3 to 100) to relieve itching. It requires watching. 
Where it cannot be used, cocaine (2 or 5 to 100) or lead, zinc, or 
bismuth ointment may take its place. Where the surface healing is 
slow, the proliferation of tissue can be accelerated by balsam of 
Peru (1 to 10) ointment. Bulkley recommends, even in acute eczema, 
alumnol, from one to five per cent, in solution, ten to twenty per cent, 
in ointments. 

Eczema seborrhoeicum (Unna) is a parasitic (microbic) affection. 
Zinc ointment should be mixed with four or six per cent, of resorcin ; 
or a solution of resorcin (from five to ten per cent.) in alcohol and 
glycerin, to be used twice a day. 

Pemphigus is more frequently observed in the newly-born (mostly 
between the fourth and eighth days ; the syphilitic form of the soles 
and palms even earlier) and very young than in older children, 
mostly on the face and trunk, with a pale or hypersemic basis, running 
its course when benign and sporadic, inclusive of the drying of 
scabs, in from six to twelve days. It is seldom chronic, and mostly 



PEMPHIGUS. NEUROPATHY 4 8i 

so mild that no scabs remain, except when it is complicated with diph- 
theria or general cachexia. In such cases the bullae may be hemor- 
rhagic, or even gangrenous. The serum (albuminous and mostly 
neutral or alkaline) contained in the bullae, which spring up, with 
no or a very thin aureola, at some distance from one another, becomes 
turbid after some days. There is rarely any fever. New crops may 
start up. Strelitz and Almquist gave themselves pemphigus through 
transferred cocci. Riehl found in a single case a fungus resembling 
very much the trichophyton tonsurans. It is often found on chil- 
dren in institutions, and will also spread to nurses or to members 
of the same family; it seems, therefore, to be contagious, and may 
be disseminated through careless midwives. In such cases staphylo- 
coccus pyogenes aureus was found. Isolated cases are the result 
of hot bathing and bedding. Thus it seems that this disseminated 
pemphigus may be either the result of microbes (staphylococci, like 
those of impetigo) or of mere cutaneous irritation, particularly at 
the time when the surface is most vulnerable, — that is, in the newly- 
born. Pemphigus exfoliativus, or dermatitis exfoliativa, is a very 
serious form which is apt to terminate fatally in one-half of the 
cases. According to Ritter, it begins at the mouth on the first or 
the fourth day of life and extends all over the body, with an angry 
redness, phlegmons, and gangrene. It was observed in hot seasons, 
after hot bathing, in sepsis. Riehl discovered a fungus with long 
mycelium. No scabs form, but relapses take place contiguous to the 
first starting-point. Dermatol, aristol, bismuth subcarbonate, pow- 
dered or in a five- or fifteen-per-cent. lanolin ointment, with soft 
covering, warmth to the feet, stimulants, and no bathing, is the appro- 
priate treatment. The treatment is suggested by the causes thus far 
enumerated. Beware of heat and of contagion. Cleanliness and dis- 
infection are required as preventive and curative measures. Astrin- 
gent ointments or bismuth powders are demanded locally, particularly 
where the epidermis has been torn off; general roborant treatment 
is required for puny and cachectic children, and antipyretics if (in 
exceptional cases) the temperature rise to an unbearable degree; 
for even delirium has been observed in older children. In most cases 
powders of bismuth, talcum, amylum, zinc oxide, etc., render good 
service; in ulcerous cases orthoform, or iodoform once or twice a 
day, or a solution of silver nitrate (i to ioo or iooo), or fuchsin 
ointment (p. 472). 

Neuropathic affections of the skin are sometimes congenital; 
while not always connected with cerebral defects resulting in paraly- 
sis or epilepsy, like the papillomata described by Neumann (fissured 

31 



482 DISEASES OF THE SKIN 

warts following the course of a nerve and covering the whole side 
of a body), still, they are serious enough, and sometimes not influenced 
by treatment. The congenital disposition to the formation of vesicles 
is in later life often combined with other neuropathic symptoms. A 
febris bullosa has been described both in children and adults. It 
is reported to be contagious, to have constitutional symptoms, and 
to run a course like acute exanthemata. It should not be forgotten, 
first, that diagnoses may be mistaken, that the symptoms of disorders of 
circulation and of innervation may be very variable, and that on princi- 
ple it should always be considered risky to coin different names for 
slight varieties. The pemphigus neuroticus chronicus of the mouth de- 
scribed by me (Trans. Ass. Am. Phys., 1894) cannot be mistaken. 
Common warts are probably, in many instances, trophic disorders of a 
neurotic character; their sudden appearance in great numbers and 
their sometimes unexpected disappearance seem to prove it. While 
fuming nitric acid is a fair local application, the internal use of arsenic 
is often of much advantage. This is certainly the case in what has 
been noticed first by Hebra as " verrucas planse juveniles," and care- 
fully described by Thin. These warts are met with in children and 
adolescents on the face and back of the hands and fingers ; they are 
yellowish or reddish brown, of the size of a pea or less, flat with a 
central depression, and may have frequently been mistaken for lichen 
ruber planus. 

A neuropathic oedema has often been described, and is easily over- 
looked when moderate. In a case described by Widowitz it occurred 
after exposure to cold, with extensive tumefaction, livid edges, and 
without any complication on the part of the heart or kidneys. A 
neurotic cyanosis has been reported by Tordeus, and by him connected 
with " dentition ;" vitiligo in a boy of six years by Wladimiroff. The 
eyelids, lips, tongue, pharynx, larynx, the orbit, (recurrent exoph- 
thalmos), the joints (hydrops articulorum intermittens) , the kidneys 
(polyuria), the mucous membrane of the intestine (nervous diar- 
rhoea) and of the bronchi (nervous asthma) may thus be affected. 
Exposure and winter weather are among the causes and suggest 
preventive treatment. This angio-neurotic oedema and urticaria should 
be considered as the result of similar causes. 

Urticaria should be treated locally and for its causes (irritation 
of the skin by scratching, vaccination, epizoa or insects, digestive 
disorders, medicines like quinine, santonin, balsamics, foods like 
oysters, strawberries, or fish, uraemia, diabetes, etc.). Locally, wash- 
ing with carbonic acid waters (siphons), with one- or two-per- 
cent, carbolic acid solutions, dilutions of chloroform and spirit of 



URTICARIA. HEMORRHAGE. GANGRENE. SCLERODERMA 483 

camphor, corrosive sublimate in three hundred parts or more of 
vinegar and water, one-per-cent. solutions of menthol, and cold cream 
or vaseline should be used. Internally, stomachics, purgatives, and 
ichthyol will often do good. The latter may be given a long time 
with or without liquor arsenitis potassii. 

Urticaria pigmentosa was described first by Nettleship in 1869. 
It originates soon after birth, and lasts, with intervals and relapses, 
until the fifth year of life or longer. Red papulae, which soon flatten 
out and become pigmentous, on the erythematous surface, on the chest, 
back, abdomen, and extremities, rarely the face, still less on the palm 
of the hand or the sole of the foot. Unna found rarefied connective 
tissue with columnar cells. The usual external treatment of com- 
mon urticaria is not successful. The internal treatment with arsenic 
should not be neglected. With ductless gland administration I have 
no experience. 

Symmetrical cutaneous hemorrhage connected with cerebral dis- 
order has been reported by Epstein; erythromelalgia in a child, by 
Baginsky; symmetrical cutaneous gangrene (Raymond) of feet, nose, 
and ears, with hemoglobinuria, in a boy of three years, by Aber- 
crombie; in children of seven, eleven, and thirteen years, belonging 
to the same family, by Braman. Several of my cases were quite 
superficial, and healed readily; others terminated in loss of limbs 
or life. The disposition afforded by rhachitis, ansemia, or leucocy- 
tosis is not always demonstrable. They follow acute or chronic con- 
stitutional or infectious fevers, measles, pneumonia, typhoid, scarla- 
tina, diphtheria ; even whooping-cough, dysentery, etc., and anything 
that will so depress circulation as to result in peripheric thrombosis. 
The treatment, besides preventive measures, is locally antiseptic and 
stimulant. 

Scleroderma has many of its (fortunately few) victims among 
children. It has been observed in the first year of life (Barth). I 
saw it in a girl of three, a girl of six, a boy of ten, and one of 
thirteen years. It begins with small or larger, generally symmetrical, 
circumscribed, mostly longitudinal, discolored hyperplasias, which 
(usually) after a long time lead to atrophy, shrinking, muscular 
immobility, and contractures. There is little or no perspiration, and 
sensation is frequently impaired. I never saw a case in a child or an 
adult that did not give me the impression of a neurotic (local or 
more frequently central) origin, and of its being guided by the course 
of a nerve. The diffuse form, with normal or glossy skin and (gen- 
erally) disturbed sensation, which extends over the face, or a whole 
limb, or the whole body, has not been found in children as yet, but 



484 DISEASES OF THE SKIN 

in adult females only. Mainly in the beginning, mercurial treatment, 
bichloride or blue ointment, in long-continued small doses, did some 
good. Salol (salicylic acid) has lately been recommended by A. 
Philippson, who reports two recoveries (adults) under doses of 
from two to three grammes (thirty to forty-five grains) daily. L. 
Weber improved a case by giving thyroid (Med. Monatssch., Octo- 
ber, 1897). De Renzi recommends the injection of a few minims 
of a ten- or fifteen-per-cent. solution of thiosinamin, Blocq electro- 
puncture. 

Herpes (group eruption of small vesicles on a hypersemic aureola) 
is mostly seen in fevers, such as pneumonia, meningitis, influenza, 
also in dyspepsia. Powdering with boracic acid, dermatol, zinc stea- 
rate, or the application of lead wash or a one-per-cent. solution of alum 
in water. Herpes zoster is mostly found on the lips (chin), in the 
mouth, and over one or more intercostal nerves, also over the nasal, 
frontal, sciatic; never over motory fibres when alone; seldom in 
the severe neuralgias met with in the adult. The irritation is periph- 
eric almost exclusively, seldom in the ganglia, very rarely in the 
cord (bilateral chorea). In the latter case the spinal (myelo-) menin- 
gitis requires calomel and ergot, also salines and digitalis; rarely the 
thermo-cautery. The usual cases require the local treatment of herpes, 
a daily dose of quinine with antipyrin, and repeated doses of the latter 
or of aspirin. 

Scabies is apt to become chronic in children because it is often 
mistaken for or complicated with the various forms of eczema and 
" prickly heat." Errors may readily take place, because it is not pre- 
eminently the fingers which are affected, but also the face, the gluteal 
region, the abdomen, and the joints. These localities constitute a 
difference from prurigo, in which the extensor sides of the extremi- 
ties are principally affected. The skin must be thoroughly cleansed 
with soap every morning, after balsam of Peru, or balsam of Peru 
15 parts, alcohol 10 parts, or balsam of Peru and vaseline, in equal 
parts, have been copiously applied the evening before. A few such 
applications will suffice, but they stain the linen. The unguentum 
sulphuris of the Pharmacopoeia is too irritating to be applied to the 
skin of children, but may be mitigated by the addition of fat, styrax 
liquidus, and olive oil, in equal parts; creolin (from 5 to 10 parts in 
100 parts of olive oil) or naphtol with fat (5 to 15 or 100) will also 
render good service. The clothing must be thoroughly washed in 
hot soap and water or disinfected with sulphur. Both naphtol and 
styrax may irritate the kidneys, so that they are contraindicated in 
children with renal affections. In them, Wilkinson's ointment (ol. 



HERPES. SCABIES. IMPETIGO. FAVUS 485 

rusci, flor. sulph., aa 20 parts ; sapon. virid., vaselin., aa 40 parts ; 
cret. alb., 10 parts) is advisable. 

Impetigo contagiosa has thinner vesicles than pemphigus, no 
fever, and no inflammatory basis. It is found on the uncovered parts 
of the body, face, hands, and feet; the vesicles are small or large 
and spread rapidly, and relapses take place. Serious results have 
not been noticed; still, a case of nephritis is reported as a sequela 
in a girl of twelve years. It is met with in schools and after whole- 
sale vaccinations, through infection by vaccine lymph. Lassar found 
the staphylococcus aureus. As many as a thousand cases have been 
observed in a single epidemic. The treatment must be preventive, 
if opportunity be given ; a school in which the disease is found ought 
to be closed temporarily and disinfected. The local (and general) 
treatment is that of a mild eczema. 

Favus is, through its achorion Schoenleinii, eminently contagious 
from child to child and from animal (rabbit, cat, dog) to child, is 
communicated through beds, caps, and finger-nails, and is not con- 
fined to the head. A mild treatment may first be tried. Green soap 
and warm fomentations will succeed in removing the hard masses, 
and solutions of corrosive sublimate (1 to 100 or 300) and ointments 
of naphtol (five per cent.) or pyrogallic acid (ten per cent.) may 
prove beneficial. Or a ten- (or less) per-cent. ointment of chrysarobin 
may be tried (according to Wolff) daily for six weeks, alternating 
it with a corrosive sublimate ointment (1 to 100). After that time, 
if the treatment have been tolerated, the application should be made 
every other day, and later once a week. The unguentum hydrargyri 
ammoniati will do the rest. I rarely saw a case improved without 
epilation, after a thorough removal of the yellow crusts by means of 
green soap and fomentations. Epilation can be done by pincers or 
by the old method of the pitch-cap, which is applied after the hair has 
been cut to one-third or one-half inch in length. Biedert modifies 
the old plan by melting two hundred and fifty parts of white pitch 
and four of tallow. The mixture is then spread over a cloth from six 
to eight square inches in size, which is fastened on the hair stumps 
with a hot iron and allowed to remain an hour before it is pulled 
off. This procedure is repeated every six or eight days until the cra- 
nium is entirely bald and smooth. The pain can be overcome and 
the cruelty of the necessary process moderated by the use of an anaes- 
thetic. Very obstinate deposits must be scraped out. 

Herpes tonsurans (from trichophyton tonsurans, a parasite very 
similar to achorion, common among domestic animals: circular vesi- 
cles, enlarging) requires a treatment similar to that of favus, in- 



486 DISEASES OF THE SKIN 

eluding epilation. Before resorting to it, ointments of sulphur, 
ichthyol, salicylic acid, or chrysarobin may be tried. Corrosive 
sublimate (i to ioo) in solution and naphtol ointment are very 
efficacious. 

Molluscum contagiosum (light nodes from which lobulated whitish 
masses containing brilliant oval bodies, perhaps protozoa, can be 
squeezed out, mostly on the uncovered parts of the body) is very 
contagious and is met with epidemically. Communication from child 
to child or from baby to nurse must be guarded against, the morbid 
growths removed with the sharp spoon and the wounds treated anti- 
septically (best with carbolic acid), and finally, if required, with 
balsam of Peru or ointments containing it. 

Lupus is in some of its forms (exfoliativus, tuberosus, exulcerans, 
serpiginosus) not accessible to anything but external treatment. Still, 
the treatment of the patient, who, as a rule, shows more symptoms of 
scrofula than of tuberculosis, is not excluded. Zinc chloride has been 
mixed with two or three parts of 'starch and made into a paste with 
water. Its application is very painful and its effect slow. So are 
Lannelongue's repeated injections of a ten-per-cent. solution of zinc 
chloride in water; still more so Milton's indefinite and persistent use 
of carbolic acid and of a twelve-per-cent. solution of potassium hyper- 
manganate (joined to the internal administration of arsenic, potas- 
sium iodide, and mercury). Another method consists in the repeated 
application of saturated solutions of lactic acid ; still another is the 
use of the sharp spoon, and then for three or five days in succession 
that of a ten-per-cent. mixture of pyrogallic acid. Wherever the 
affected part is not too large, and in a convenient locality, excision 
ought to be made and the wound closed ; should it be too large for 
that, transplantation may be performed afterwards. At all events, 
the destruction of the morbid part, wherever aimed at, is most easily 
accomplished by the actual thermo- or galvano-cautery. Tuberculin 
has failed here as in other cases of tubercular disease. A paste com- 
posed of arsenous acid I part, hydrarg. sulph. rubr. 3 parts, vaseline 
15 parts (or another menstruum), applied daily for several days in 
succession, has a deserved reputation for destroying the morbid 
masses. Both the Finsen light and the X-ray treatment are still in 
their experimental stage. 

Lupus erythematosus has its localized inflammatory cell-infiltra- 
tions near the surface, particularly in its most recent disseminations. 
That is why it may be most amenable to treatment. I. Schiitz treated 
nine cases with two daily applications of a mixture of 4 parts of 
Fowler's solution in from 20 to 30 of distilled water. When after four 



MOLLUSCUM. LUPUS. PSORIASIS. NEOPLASMS 487 

or six days the surface became irritated, a mild powder was substi- 
tuted for a few days, and the treatment resumed after four or eight 
days. The cases got well in from ten to eleven weeks, without 
scars. 

Tuberculosis of the skin (both verrucosa and ulcerosa) may 
be treated with the actual cautery and with mercurial plaster ; scrofu- 
loderma (nodes in and under the skin of the face, neck, and extremi- 
ties, with central softening and a cheesy pus), by arsenic internally 
and the sharp spoon, and subsequently iodoform and balsam of 
Peru. 

Psoriasis, when acute, is a very distressing disease because of 
its intense itching. It has been known to originate from local irri- 
tation in the scars of vaccination (Bethman) or variola (Cazenave). 
It requires many and protracted baths and plenty of soap to remove 
the scales ; unguentum hydrargyri ammoniati is used for the same 
purpose. Ichthyol ointment (from five to ten per cent.) has rendered 
me good service in the only case I have seen in a child for years. Beta- 
naphtol has been highly praised in ointments containing from five to 
ten per cent. Neisser recommends chrysarobin or anthrarobin oint- 
ments ( from five to ten or twenty per cent. ) . They are positively dan- 
gerous in such doses, when used on children, because of the extensive 
erythema and conjunctivitis following them. On the head, therefore, 
he substitutes pyrogallic acid, but it dyes the hair black and is not 
so efficient. For chronic cases the principle of treatment is the same. 
The eruptions must be attended to locally ; ichthyol ointments will also 
do some good. Chrysarobin ointments (from one to two per cent.), 
or chrysarobin in traumaticin in the same proportion, should be applied 
once every day or every few days. Green soap, or liquor potassii, a 
daily bath in soap and water, will dissolve the scales and facilitate 
the effect of the other applications. Internally, iodides will prove 
effective in syphilitic cases. Thyroid in small doses (one to two grains 
= 0.06 to 0.125 daily) has had some successes among many failures. 
The best internal remedy is arsenic in long-continued moderate doses. 
No stimulating food (no dark meat, or no meat at all) or beverages. 

A number of congenital diseases of the skin and subcutaneous 
tissue are amenable to treatment; to them belong the neoplasms. 
Lipoma is found in two varieties : first, the circumscribed and capsu- 
lated; second, the diffuse. While the former is as easily removed 
as in the adult, the latter is sometimes inoperable, inasmuch as it 
extends over large areas, and resembles in some instances, or in some 
parts of the anomalous growths, a moderate or formidable surplus 
of normal fat only. I had to give up an operation for removal before 



4 88 DISEASES OF THE SKIN 

it was completed. Hard fibroma (connective tissue, circumscribed 
tumors) should be extirpated before it gives rise to facial leontiasis 
or elephantiasis (Trendelenburg). Soft fibroma (f. molluscum Vir- 
chow, mostly multiple, with a tendency to immense growth, some- 
times pendulous, connective tissue with areolar structure) should be 
removed quickly from the cutis in which it develops. Keloid is an 
hypertrophied cicatrix extending upward from the corium, with rapid 
growth. Extirpation is useless because of the new development of 
keloid. Daily painting with liquor potassii arsenitis and ointments 
of ammonium sulpho-ichthyolate in lanolin and fat, aa 5 to 8 parts, 
may be tried. Repeated semi-weekly subcutaneous injections of a 
ten-per-cent. solution of thiosinamin in absolute alcohol (doses for 
adults grs. 2 /z to \y 2 — 0.04 to 0.1) have been recommended, as also 
for cicatricial contractures following lupus, etc. (Sinclair Tousey). 
Cysts and dermoid cysts are met with; many of them, though con- 
genital, attract attention only after months or years. Atheromata 
(when small and superficial, embedded in skin only, — milia) are not 
infrequent about the head (eyebrows, etc.). They can readily be enu- 
cleated, and ought to be removed before they adhere to the skin and 
undergo suppuration. When they are suppurating, and removal is 
very difficult or impossible, tartar emetic in water (1 to 30) may be 
injected or potassium hydrate introduced. Either of these will dis- 
integrate the cyst-wall to such an extent as to render their removal 
by pincers possible after a day or two. Congenital sarcoma has been 
described a few times, once by Neuhaus {Arch. f. Kinderh., vol. 
xxii., 1897) , who collected a few other cases. The sarcoma commenced 
in the subcutaneous tissue. The only one beginning in the cutis 
itself was recorded by me for the Am. Fed. Soc, 1897. It was on 
the upper part of the scrotum, with small metastases on the dorsum 
penis and no swelling of lymph-bodies. It was excised, the meta- 
static deposits destroyed with the thermo-cautery, and the baby treated 
with arsenic {Arch, of Ped., November, 1897). 

Congenital ichthyosis is the result of an hypertrophy of the epi- 
dermis and the papillae of the corium, sometimes with dilatation of 
their blood-vessels, also with sclerosis of the connective tissue, and 
usually with an exaggeration of the normally copious secretion of 
sebum during the second half of intra-uterine life. The elastic fibres 
are more or less absent. Sebum not removed, but thickened by epider 
mal cells and foreign material, forms scales, which may be thrown 
off, but are rapidly reproduced, and cause fissures and warts. This 
condition, when mild ("xeroderma"), is not necessarily dangerous 
to life. A boy of fifteen was freed of his scales by a permanent warm 



SKIN ATROPHY. NEOPLASMS. N/EVUS PIGMENTOSUS 489 

bath of five days. Lanolin inunctions, with or "without ichthyol (from 
five to ten per cent.), will prove beneficial. Arsenic should be given 
internally. Thyroid — with which, however, I have no experience in 
this anomaly — was given by Joseph and others with apparent success. 
I should favor its use also in congenital idiopathic atrophy of the 
skin (head, face, hands, feet, nails, hair, which is totally absent), which 
otherwise is not reached by treatment. The effect of thyroid in myxce- 
dema and its alopecia should encourage us. 

The worst forms of congenital ichthyosis, which sometimes ter- 
minate fatally in a few days, are not amenable to treatment. Partial 
follicular ichthyosis, in which bony spinae grow out of hair- and 
tallow-follicles without affecting the general health, demands fre- 
quent bathing, green soap, plenty of fat inunctions, and a ten-per-cent. 
sulphur ointment; also salicylic acid in a saturated alcoholic solu- 
tion. 

Congenital neoplasms on the neck are: hygroma (lymphangioma 
with albuminous contents and endothelia) ; serous and dermoid cysts, 
sometimes so dense as to render their diagnosis from lymphatic tumors 
difficult when situated below and alongside the sterno-cleido-mastoid 
muscle; carcinoma and epithelial remnants of the branchia; primary 
endothelioma of the lymph-follicles; and sanguineous cysts, mostly 
diverticula of veins, or in a few cases rudimentary developments of 
the jugular vein. They require either enucleation or an extensive 
incision with aseptic tamponing. 

Ncevus pigment osus and verrucosus * belong here. Their treat- 
ment is similar to that applicable to vascular nsevi and tumors (p. 
468), the latter differing from the former by a greater prominence 
of the skin, which is produced by elongation of the papillae and by 
hyperplasia of connective tissue ; also to the ncevus lipomatodes, which 
is a spherical or cylindrical fatty excrescence covered with normal 
skin, sometimes pedunculated, sometimes sessile and with a broad 
basis. A few of the latter class are liable to grow out of proportion ; 
all the rest in conformity with, or even less than, the rest of the body. 
In the majority of cases the time for an operative procedure is left 
to the medical attendant. Besides the methods of removal which 



* Solden (Arch. f. klin. Chir., vol. lix.) claims it as a fibromatosis of the 
connective tissue of the nerves. The " naevus cell nest" is not epithelioma 
(Unna) nor lymphangiofibroma (Recklinghausen), but neurofibroma. Out 
of this are developed the soft warts and the soft fibromata, the nerves of the 
skin and the whole periphery participating. Pigmentation in the rete Malpighii 
is a different process (melanosis). 



490 DISEASES OF THE SKIN 

have been detailed above, total extirpation is advisable in most cases. 
Indeed, it is the preferable method. Local anaesthesia can easily be 
accomplished by ethyl bromide, or by a mild solution of cocaine 
(grs. 3^2 or 2 to ioo), or by Schleich's solution, mentioned on page 72, 
injected into the skin. Excision is readily executed with but little 
loss of blood, and the sutured wound is covered with collodion. In 
a very few days, without a change of the collodion, recovery is apt 
to be complete. 



XII 

Diseases of the Muscles 

Acute inflammation of the muscles — myositis — is located either 
in the external or internal perimysium, also in the contractile ele- 
ments. Cellular infiltration, coagulation, fatty and hyaline degenera- 
tions, suppuration, nuclear proliferation, and the formation of new 
connective tissue are observed as its morphological changes, with 
either incurable retraction or curable contraction as their results. 
Traumatic myositis (p. 90) requires absolute rest, the application 
of cold water or ice, after a while tincture of iodine once a day 
or every other day, potassium iodide and lanolin ointment several 
times a day, or gentle massage without the ointment. Potassium 
iodide internally is indicated when thickening remains. If, after a 
long time, the muscle, though without pain, does not become nor- 
mal, the electrolytic effect of the galvanic and the stimulating action 
of the interrupted current, in short sessions, may improve the con- 
dition. Both traumatic and rheumatic myositis have a tendency to 
relapses. The latter requires a treatment similar to that which has 
been detailed above, with this exception, that hot (dry) applica- 
tions generally render better service, and the internal administra- 
tion of sodium salicylate is mostly indispensable. Inunctions of oil 
of wintergreen are often useful, as are also diaphoretics. The in- 
fectious myositis of eruptive and septic fevers starts with a mod- 
erate increase of temperature, some sensitiveness on pressure, and 
occasional swelling, an effusion which is either serous or purulent, 
and requires accordingly, besides the active attention demanded by 
its origin and a careful differentiation from a possible affection of 
a joint, either expectant or operative (and antiseptic) treatment. In 
those rare cases in which purpura is observed at the same time, the 
myositis has probably a hemorrhagic origin, Neuritis and myositis 
may appear together, as neuromyositis, acute, subacute, or chronic, 
without or with relapses. It is rare, but of long duration, probably 
always of bacteric origin, and shows all forms of parenchymatous, 
interstitial, embolic, and hemorrhagic changes. Syphilis produces 
either gummata, which are often mistaken for sarcomata, or hyper- 
plasia, and demands, in addition to internal specific treatment, either 
the inunction of an oleate of mercury or of the blue ointment or sub- 
cutaneous injections of the bichloride. Tubercular deposits are 

491 



492 DISEASES OF THE MUSCLES 

caseous and purulent ; they must be incised, scraped out and irrigated, 
and the cavity filled with iodoform gauze. Purulent myositis is hardly 
ever idiopathic, and its cause or complications must be ascertained 
(syphilis, tuberculosis, sepsis). 

The chronic forms of myositis met with in children are, as a rule, 
outgrowths of the acute inflammation. The rare forms of trau- 
matic ossifying and of petrifying myositis are hardly ever seen in 
childhood, with the exception of the occasional appearance of the 
multiple progressive ossifying variety, — a collateral to the cartilag- 
inous exostoses, — which exhibits in (slightly febrile) acute attacks, 
or chronically, different stages (embryonal, fibrous, ossifying) of 
inflammation and bone-formation in the cellular tissue of the fasciae, 
in the aponeuroses, and in the tendons of the back, the chest, the mas- 
seter, and the extremities; seldom of the abdomen, never of the 
heart, the diaphragm, or the sphincters. Sometimes it is compli- 
cated with absence, undersize, or ankylosis of the phalanges of the 
thumb or fingers. It is a nutritive disorder, always of congenital 
origin. Of forty-two cases (A. Weill and J. Nissin in Nouv. Iconog. 
Salpet, 1898), twelve were noticed under one year, twelve from the 
second to the fifth, and ten from the fifth to the fifteenth year. No 
available treatment is known. 

Ischcemic muscular paralysis is the result of anaemia (mostly 
local, as from the influence of cold). The pain, loss of elasticity, 
and resulting contracture require massage, gymnastic exercise and 
electricity, and the subcutaneous daily use of strychnine. 

Trophoneurotic ill nutrition and paralysis comprise two varieties. 
One is the result of inflammation of a joint : from disuse the neighbor- 
ing muscles become atrophic and more or less paralyzed. The other 
originates in a change of the spinal centres, as in poliomyelitis, with 
fatty degeneration and atrophy as inevitable consequences. In both 
varieties systematic massage of the paralyzed muscle, executed with 
anatomical knowledge, will do good ; in the first with mostly complete 
success. Electrical treatment and strychnine may be combined with 
it. The atrophy is very rapid, with but slight changes of electrical 
irritability (no reaction of degeneration), and localized. If the knee 
be affected, it is the quadriceps that is suffering; if the hip-joint, 
the glutaei ; if the shoulder, the deltoid, infraspinatus, and teres minor ; 
if the elbow, the triceps ; if the wrist, the extensors of the forearm ; 
if the fingers, the interossei. 

The pseudo-paralysis of rickety children is simply debility. Par- 
rot spoke of pseudo-paralysis as the result of epiphyseal swelling. 
When the spinal cord is found altered (hemorrhage, abscess, cocci 



MYOSITIS. PSEUDO-PARALYSIS. TORTICOLLIS 493 

in the fine vessels), there is no longer a " pseudo," but an actual 
paralysis. In congenital syphilis, muscular debility, with normal 
electrical irritability, may be observed about the first or third month 
of life. Muscular atrophy, progressive juvenile muscular dystrophy, 
pseudo-hypertrophy, and congenital myotonia have been mentioned 
above (p. 271). 

The affection which has been described as grave pseudo-paralytic 
myasthenia, and which consists in a peculiar exhaustion of the mus- 
cles on slight exertion, to such an extent as to render voluntary con- 
traction very difficult and to rapidly diminish electrical excitability, 
appears to depend either on defective innervation or on chemical 
changes. In the single case I have seen, in which no causal diagnosis 
could be made or suspected, except a general muscular debility com- 
mon to most members of the same family, massage and strychnine 
rendered some service. Veratrine, physostigmine, and digitoxin are 
recommended. In neurasthenia the muscles are also unduly exhausti- 
ble, but it differs from myasthenia in this, that the nerves are excita- 
ble. A good many cases so described should be thoroughly studied. 
The results of polioencephalitis or other brain lesions and the incipi- 
ency of brain tumors have often been taken for " myasthenia." 

Torticollis {caput obstipum) means a contraction of the sterno- 
cleido-mastoid muscle, mostly its sternal end; the head is turned 
to the affected, the face to the opposite side, and the diseased side is 
not infrequently more or less atrophic. The treatment depends to 
a great extent on the cause of the contraction. Spasmodic torticollis 
resulting from reflex of the sensitive nerves of the cervical plexus 
requires the section of the latter. Malposition in the uterus is an 
occasional direct source, as also the hematoma originating during 
birth, or later, which has been mentioned elsewhere (p. 90). Bilateral 
caput obstipum, with the result of forcing the head backward, has 
been observed in very young infants. In a case of Shaffer the head 
was drawn forward. No blood was found in the muscles, but only 
firm connective tissue and atrophy of muscular fibres. This inter- 
stitial fibrous myositis depended, probably, on a number of minute 
traumatic lesions during parturition. Tumors, such as sarcomata, 
have the same influence on the function of the muscle. This is 
impaired, in advanced childhood, by sudden strains ; for instance, 
by kite-flying, by loads carried on one shoulder, occasionally also by 
an abnormal position of the head, enforced by paralysis of the ocular 
muscles, in order to avoid double vision (Landolt). Rheumatism of 
the muscle, isolated or more general, and of one or more vertebral 
articulations, and caries of the vertebrae have the same effect. Sodium 



494 DISEASES OF THE MUSCLES 

salicylate internally, oleum gaultherise, and ammoniacal or camphor 
inunctions will do good. The same may be said in regard to muscu- 
lar rheumatism in general. Torticollis is also one of the symptoms 
of the acute rheumatism of the neck which, because of its serious 
symptoms (fever, vomiting, delirium, with no irregularity, however, 
of the pulse), has been mistaken for meningitis. Sometimes it de- 
pends on a neurosis (neuritis?) of the accessory nerve. In that case 
the scalenus and trapezius muscles are also affected. Reflex torticollis 
has been mentioned in connection with intestinal worms and with 
carious teeth, and an intermittent form is known to exist (Forch- 
heimer) and to depend on malaria. In these cases quinine and arsenic 
are indispensable. Worms must be removed, teeth corrected. A. J. 
Gillette says that he cured a case by the removal of adenoid growths. 
In those cases in which heavy loads carried on one side cause contrac- 
tion of the other a systematic use of the diseased side will restore the 
equilibrium. Exaggerated and forcible swinging of the arms will 
secure co-operation and exercise of the muscles of the neck. Massage 
both of the muscles and of the articular processes of the cervical 
vertebrae from the third to the fifth is required. The galvanic cur- 
rent in mild doses relieves spasm. Gentle rubbing with lanolin (in 
inflammatory cases with potassium iodide or mercury) is beneficial. 
Cold temperatures must be avoided. Otherwise unconquerable cases 
require tenotomy, to be performed by open incision, which protects 
the jugular vein better than the old operation from inside outward. 
When tenotomy is not sufficient, Mikulicz practises the total extirpa- 
tion of the sterno-cleido-mastoid muscle. Too violent attempts at 
reduction may prove dangerous. Brackett (Eleventh Meeting Amer. 
Orth. Assoc, 1897) met with alarming changes in pulse and respira- 
tion, which he attributed to adhesion and shortening of the pneumo- 
gastric nerve. 



XIII 

Diseases of the Bones and Joints 

i. Congenital Anomalies. 

Of the congenital malformations of the extremities (bones and 
soft parts), many are not accessible to treatment. To this class 
belong arrests of development, either before or after their formation, 
and spontaneous amputations. Curvatures of the limbs (congenital, 
through fracture of the tibia) may require osteotomy or osteoclasy ; 
but their domain is not very extensive, for in the large majority of 
acquired rhachitical curvatures of the legs recovery takes place spon- 
taneously. Observations in the surgical clinic of Tubingen, extend- 
ing over a number of years, prove that seventy-five per cent, of all 
such curvatures will straighten in from two to four years. When 
the patients were first presented, plaster-of-Paris casts of the de- 
formities were made, and another examination took place after an 
average of four and one-half years. Improvement was noticed in 
15.3 per cent, additional. In 9.7 per cent, only no spontaneous recov- 
ery or improvement took place. It is in these that operations are 
demanded. Supernumerary fingers and toes are either removed from 
their cutaneous attachments or extirpated from their sockets. Con- 
genital enlargements of toes, consisting in hypertrophy of both bone 
and fat, are removed by amputation. Universal giant growth is 
always congenital, but not hereditary. The connective tissue, muscles, 
bones, and blood-vessels, all of which evolve out of the mesoderm, 
are equally affected. The nervous system and the joints are normal, 
the skin sometimes thickened, the nails correspond with the phalanges. 
Whether it is related to acromegalia (which in its full development 
is observed in later years only, but may originate earlier) remains to 
be seen. For the present it is not amenable to treatment. Synechia 
of {webbed) fingers and toes must be separated; the operation being 
difficult, it is best to delay it for some time, but not long enough to 
endanger the growth of the organ. Division of web, with suture 
of the preserved skin on one finger and Thiersch's grafts on the 
other, or the latter on both fingers, is asserted to be the best treat- 
ment. 

Multiple infantile exostoses are congenital, sometimes hereditary, 
very rarely syphilitic, and then recognized by, or connected with, 
other symptoms of syphilis ; they develop early, now and then only 

495 



496 DISEASES OF THE BONES AND JOINTS 

after puberty ; grow near the periepiphyseal cartilage, between epiph- 
ysis and diaphysis, sometimes from the cartilage of the epiphysis ; 
sometimes found on scapula, pelvis, and cranium; in rare instances 
grow even after the completion of the growth of the body; in some 
instances surrounded by a synovial membrane (exostosis bursata) ; 
remain cartilaginous or become osseous, and then may interfere with 
the growth of the bones. They do not often disturb the functions 
of the long bones and joints, but the ulna has been known to be- 
come crippled by them, the skin may ulcerate over them, and the 
synovial capsule may be raised by one growing too near the joint. 
These complications sometimes require special treatment and atten- 
tion. Exostoses, so long as they are but few and not cumbersome, 
are best let alone. However, in the next case of early age seen 
by me I shall give phosphorus (p. 130) systematically, for the pur- 
pose of enforcing speedy ossification, both local and general. Ex- 
tirpation is indicated when there are but few, and when these are 
large; under careful asepsis the operation is at present devoid of 
danger. Potassium iodide has been administered extensively without 
apparent effect. When syphilis is suspected, mercury and iodides 
should be given a trial. 

2. Congenital Luxations. 
Congenital luxation of the hip-joint, with the exception of rare 
cases .depending on injuries contracted during birth, is the result of 
scantiness of liquor amnii, by which, in the cramped position of the 
foetus, the growing femur is pushed out of the socket, or, in other 
(rarer) cases, of an arrest of development of the acetabulum, which 
is sometimes hereditary and now and then complicated with other 
malformations. The head of the femur finds no accommodation, and 
the trochanter is found above its normal place. This is particularly 
so on the steep os ilium of the female. When the luxation is uni- 
lateral the gait is limping; when bilateral, waddling. Extension 
lengthens the extremity and conceals the deformity. Treatment is 
either mechanical or operative. Until a few years ago the mechanical 
treatment was the only one generally recommended. Volkmann relied 
on permanent extension, particularly in unilateral cases. Hesing has 
good results with his apparatuses. Schede uses splints, with pelvic 
support, to extend and to abduct the extremity, for from two to 
four years in succession. He finds the indication for this treatment 
in bilateral cases up to the fourth year, in unilateral cases up to the 
eighth or ninth, for the rudiment of the acetabulum whose size can 
be improved upon frequently persists up to that period of life. Paci 



EXOSTOSIS. CONGENITAL LUXATION 



497 



lost a girl of seven years by dysentery four months after reduction 
and extension of her bilateral dislocation; he found at the autopsy 
two new joints which appeared to promise stability of the femoral 
head in the new position, if the child had lived. Ten years ago the 
results of operations appeared to be very favorable. At the Con- 
gress of German Surgeons of 1894, Lorenz — in that of 1895, Hoffa 
— presented very satisfactory statistics and patients. Neither of them 
cuts the muscles, but both reduce the dislocated limb by powerful 
extension. Hoffa's incision is longitudinal, like that made for re- 
section (Langenbeck) ; the capsule and soft parts are loosened from 
the trochanter by subperiosteal operation, the acetabulum is enlarged 
and the head fitted into it. The superfluous capsular tissues are then 
extirpated, the wound is filled with iodoform gauze, and an exten- 
sion apparatus applied. The extremity begins to grow, shortening 
becomes less, and both head and acetabulum gradually increase in 
size. Hoffa's operations were performed between the second and 
eighth years. He presented the statistics of one hundred and twelve 
operations performed on eighty- two patients without cutting muscles. 
The last forty-seven terminated without a death. Lorenz's incision 
runs anteriorly; he does not touch the insertion of the muscles. 

Later, A. Lorenz * published his objections to the protracted em- 
ployment of extension, which keeps the patient in a recumbent 
position, possibly for years, and interferes with the nutrition and 
function of the limb or limbs. Instead, he extended forcibly, under 
anaesthesia, and reduced the head of the femur, the reposition being 
maintained by strong abduction. The head of the femur is then re- 
tained in the small acetabulum by apparatuses and the abduction is 
gradually diminished. After a while standing and walking are per- 
mitted. At first, while abduction is continued, these movements are 
clumsy and difficult, but when the weight of the body and the con- 
stant friction have deepened the acetabulum, they become easier by 
degrees. The oldest child in whose case this procedure was success- 
ful, the luxation being bilateral, was six years and three months. 
In one case of unilateral luxation standing and walking were inter- 
rupted three days only, in others several weeks. Even when the 
luxation was bilateral they were not long delayed. Two patients 
were able to stand, in six weeks. To ascertain the actual result of 
a successful reduction, the X-rays have been employed before and 
after the treatment. As a result of more mature experience, public 
opinion among surgeons is swinging back to mechanical treatment 

* Centralblatt f. Chir., 1895, No. 33 ; Samml. klin. Vortr., 1896, Nos. 150, 151. 

32 



498 DISEASES OF THE BONES AND JOINTS 

almost exclusively. Schede, Hoffa, Lorenz, Wolf, and Kummell 
(Assoc, of Germ. Phys. and Nat., 1896) unanimously discredit any 
bloody operation in the treatment of even severe cases. It should 
be resorted to as a last resource, and promises no success, but is risky. 
Schede reported ninety-nine cases of infants and children up to fif- 
teen years of age, ninety-eight of which recovered with manipulation 
only. Lorenz reported eighty-three cases treated by manipulation, 
and extension in abduction, successfully (A. H. Tubby, London 
Lancet, May 1, 1897). The advantages of mechanical treatment are 
its simplicity and the avoidance of the danger connected with every 
great operation, of scars, and of probable contractions in later life. 
One of the latest contributions to the subject is by A. Codivilla 
(Zeitsch. f. orthop. Chir., vol. ix., 1901). According to him, the 
bloodless treatment is easiest in early childhood. Only four or five of 
sixty-six cases reduced were perfect physiological results, but the func- 
tional result was good in practically all of them. Bloodless methods 
were successful even in cases as old as sixteen years ; the immobiliza- 
tion of the reduced dislocation in a position of more or less marked 
abduction must continue from six to nine months. 

Congenital luxation of the knee-joint is not so frequently observed 
as that of the hip-joint. Still, G. Muskat collected (Arch. klin. 
Chir., vol. liv.) seven genuine luxations, four contractures in flexion, 
and seventy-one incomplete luxations. Massage, cautious attempts 
at restoring motility, and — under the most urgent circumstances only 
— opening of the joint are recommended. 

Congenital dislocation of the scapida is rare. A mild degree is 
caused by an incompetency (congenital) of the trapezius muscle. 

Congenital dislocation of the shoidder was observed in rare in- 
stances as the result of trauma during parturition. F. S. Eve (Lon- 
don Lancet, May 1, 1897) describes two cases. In one the head 
was below the spine of the scapula; in the other the joint was found 
" normal, the head elongated obliquely backward." Redundant car- 
tilage was shaved off and reduction performed. 

Twenty cases of congenital dislocation of the radius, mostly back- 
ward, were collected by A. Ernstberger, who, like his father, had it, 
together with symmetrical anomalies of the finger-nails. In his own 
case there was also a subluxation of a patella. 

3. The Bones. 
Fractures heal the more readily the younger the patient. Callus 
is speedily formed, and, the muscles being feeble, dislocation of the 
ends of the bones does not take place to any considerable extent. 



CHONDRITIS. OSTEITIS 499 

Elixir of phosphorus in increasing doses will hasten consolidation 
in the feeble and anaemic. The fracture of the humerus occasioned 
during birth requires a light splint with but little wadding. A piece 
of pasteboard and a few strips of adhesive plaster or a bandage, 
and the support of the limb by fastening it to the body, are suffi- 
cient. Clavicles heal readily when tied up in a triangular cloth, 
the arm being fastened to the body. Fracture of the clavicle during 
labor is often followed by permanent paralysis of the correspond- 
ing upper extremity. Where moistening by urine, etc., is feared, 
the bandages should be painted with a solution of resin in ether 
(1 to 10). 

Perichondritis and osteochondritis occur, of course, in earliest 
infancy only, mostly under the influence either of rhachitis, or of 
syphilis, or of acute infectious diseases, most frequently in the forearm 
and the leg, also on the ribs or clavicles, or sternum or larynx, and 
terminate either in cutaneous infiltration or disruption of epiphyses. 
Pain is rare, and the " pseudo-paralysis" of Parrot means but the 
functional disturbance due to infiltration of the tissues. Periostitis, 
osteitis, and osteomyelitis are due, in the first instance, to the disposi- 
tion created by the activity of metabolism and by the physiological 
succulence of the bones, whose growth starts from the periosteum, 
from the marrow, and from the periepiphyseal cartilage. The vul- 
nerability of general scrofula and hereditary influences add to their 
liability to become diseased. Proximate causes of inflammation are 
trauma, colds, infectious diseases such as whooping-cough and mea- 
sles, and the invasion of cocci and bacilli through the skin, umbilicus, 
mouth, tonsils, or any other sore surface, also the respiratory and 
digestive organs, with the resulting septicopyemia. Infection may 
be intra-uterine. The termination of periostitis is either in absorp- 
tion, or thickening, or suppuration. In albuminous periostitis pus 
is substituted by serum and fat. In scrofulous and tuberculous chil- 
dren osteitis is mostly found in the short bones and in the epiphyses. 
The bones swell, become softened (porotic), and in their interior sup- 
puration loosens the tissue and dilates the medullary spaces so as to 
inflate and expand the thin external layer (spina ventosa). Tuber- 
cular osteitis softens the bones into a yellowish caseous or fungous 
mass, and thereby forms cavities, which may heal by means of ab- 
sorption of the liquid contents and calcification of the remnant, but 
mostly end in caries or necrosis, in sinuses, in persistent suppuration, 
and not rarely in amyloid degeneration. The degrees of the different 
forms vary considerably. For instance, necrosis may be superficial, 
with a favorable prognosis ; or central, with the formation of a 



500 DISEASES OF THE BONES AND JOINTS 

sequestrum the removal of which incites granulations and new forma- 
tion of bone; or total, and thus removes whole bones, such as the 
calcaneum, the cuboid, entire phalanges, or the diaphysis of the long 
bones. 

The prognosis is best when the process is superficial. Absolute 
rest, elevation of the limb, cold applications, tincture of iodine, and 
deep incision in case of very severe pain which betrays the presence 
of pus comprise the proper treatment of acute periostitis. Chronic 
thickening will usually be reduced, perhaps even removed, by moder- 
ate pressure, potassium iodide internally, and (or) an ointment of 
the same with lanolin. Syphilitic periostitis requires potassium iodide 
in increasing doses, occasionally combined with mercury. Osteitis 
and osteomyelitis (deep, agonizing pain, with but little swelling at 
first) require a treatment similar to that of periostitis. The bone 
should be kept at rest, well elevated and supported by splints, and ice 
applied. In mild and slow cases tincture of iodine or the ignipuncture 
of Kocher yields favorable results. Syphilis demands its specific 
treatment no matter where met with. It should be remembered that 
syphilitic dactylitis, in the shaps of spina ventosa, cannot always 
be diagnosticated, clinically, from the tuberculous form, also that 
syphilis and tuberculosis may be found in the same baby. In such 
cases a protracted antisyphilitic treatment is indispensable. Incision 
may strike an abscess, which is then drained. A sequestrum is re- 
moved, and will be replaced by bone so long as there is no dangerous 
general affection. Antiseptic irrigations are indicated in most of these 
cases, and antiseptic applications should be made constantly unless 
sterile gauzes be used to fill a cavity or sinus. When caseous degen- 
eration has taken place to a great extent, the question of mere 
scraping or of resection presents itself. Osteomyelitis requires an 
early operation, sometimes within a few days after the appearance 
of the first symptoms. Esmarch's bandage, the chisel, and the sharp 
spoon are the main reliances of the surgeon ; the seat of the disease 
must be reached and entirely uncovered ; counter-openings and ample 
tamponing may be demanded. Spina ventosa should be treated in 
a similar manner ; part of the remaining external osseous layer should 
be removed and the cavity filled with iodoform or other antiseptic 
gauze. Obstinate sinuses must repeatedly be scraped. They often 
heal under a carefully conducted Bier's treatment (p. 507), with 
parenchymatous injections of an iodoform emulsion into the sur- 
rounding tissue, not into the sinus itself. 

In every case of this kind — in fact, in every case of subacute or 
chronic inflammation of the osseous tissue — phosphorus ought to be 



SPONDYLITIS 501 

given. It may be continued in such closes as are recommended else- 
where (p. 131) for two or three months in succession. 

Tuberculosis of the body of a vertebra (more frequent than that 
of the arch or of a process) underlies spondylitis in almost every 
case. The intervertebral cartilages are but secondarily affected. In 
many cases a trauma is charged with being the proximate cause, in 
others the process develops spontaneously, with but few symptoms. 
Stiffness on moving, pain on moving and pressure, very little, if any, 
increase of temperature, and inability to bend and rise without support 
on a knee or some near solid object are quite often the persistent, but 
only, symptoms. When spondylitis is cervical, it is liable to produce 
headache, dyspncea, and retropharyngeal abscess; when lumbar, pain 
in the thigh or symptoms resembling those of coxitis. Usually there 
is at an early period pus either in the bone or at some distance from 
it. It finds its way along the fascia, rarely into the vertebral canal, 
and is met with in the lumbar and gluteal regions, in the small pelvis, 
along the psoas and internal iliac muscles, and along the rectum. The 
latter occurrence is unfavorable because of the slowness — if at all — 
of recovery. Lumbar and gluteal abscesses are more readily dis- 
covered than those of the psoas, and therefore more amenable to treat- 
ment. Incision, wiping out with aseptic gauze (better than irriga- 
tions), and injection of a five-per-cent. iodoform-glycerin emulsion 
will lead to recovery, provided the suppurating and tubercular ver- 
tebra heal out. Even psoas abscesses close up in that way, after 
the destruction of the pyogenic membrane. So far as the spondy- 
litis is concerned, there is, unfortunately, rarely a recovery without 
some deformity; but if treated in time and properly (corset with or 
without jury-mast), recovery may take place without it. Permanent 
gibbus should be avoided. Cases with much suppuration exhibit last- 
ing and marked kyphosis (Pott's disease), or scoliosis, or kypho- 
scoliosis. As soon as the diagnosis can be made, the patient must 
remain on his mattress, with a moderate amount of extension. Ice 
will relieve local pain. When it is moderate, tincture of iodine will 
answer. Hueter recommended the subcutaneous injection of a two- 
per-cent. solution of carbolic acid. When there is no fever, the time 
for a plaster-of- Paris jacket, according to Sayre, has arrived. What 
the latter requires, however, is that the child should not be too 
young. To be useful, a certain length of the spine is necessary. Thus, 
it is principally in the dorsal spondylitis of children of a certain age 
that it exhibits its best results. The jury-mast is added to support 
the head and thereby to reduce local pressure in cervical cases. Ab- 
scesses gravitating downward are better not touched before they reach 



502 DISEASES OF THE BONES AND JOINTS 

the surface. Then, before their spontaneous perforation, antiseptic 
irrigations and the use of iodoform emulsions are indicated. 

Most cases of spondylitis are tubercular, and either primary or sec- 
ondarily infected by a mediastinal lymph-node ; some (either tubercular 
or non-tubercular) are traumatic ; very few the result of a neoplasm. 
Abscesses are frequent and difficult to diagnosticate. They and caseous 
abscesses may cause a peripachymeningitis and narrowing of the spinal 
canal, with paralysis. This may terminate in recovery, sometimes after 
a long rest and potassium iodide, etc., treatment, sometimes after 
operations. The resection of parts of a vertebra is mainly indicated in 
old cases of (almost) complete paralysis, recovery from which may 
take half a year or a year. The disease is dangerous because of its ori- 
gin and its effect. Preventive treatment is always indicated, and me- 
chanical treatment should be gentle. Calot's earliest method of rapid 
reduction, with or without removal of spinous processes (thirty times 
in thirty-seven cases), has naturally resulted in several deaths. The 
author's intrepidity and his disregard both of human life and of public 
opinion were wonderful to behold. Later he changed his method, 
proceeded slowly — that is, " several seconds" — in accomplishing the 
reduction of the prominence, and then used plaster extension with 
a weight of from forty-five to one hundred and thirty pounds. Those 
who have followed his procedures are not edified by their results. 

A number of cases described as chronic articular rheumatism are 
undoubtedly those of arthritis deformans. The differential diagnosis 
is perhaps best made by remembering that the term " rheumatism" 
is still too vague to allow its use for diagnostic purposes. The only 
condition which deserves it is acute (or subacute) articular rheuma- 
tism, rheumatic polyarthritis. It affects the synovial membranes. 
Gout (the affection has also been called " rheumatoid gout" or " rheu- 
matoid arthritis") implies uratic deposits. Arthritis deformans is 
an affection of the cartilage (influenced by anomalies in the bones?) : 
first, proliferation between the intercellular fibrillar, then absorption, 
with, finally, hyperplastic eburnation around the absorbed cartilage 
and distortion of the limb (the hand in the ulnar direction mostly, 
with intact thumb and thoroughly enlarged phalangeal ends). A 
similar process takes place about the shoulder, elbow, knee, toes, 
and vertebrae. The heart has been found affected in a few cases, but 
as a complication with rather than a part of the disease. Marked 
cases of arthritis deformans such as I have seen myself have been 
published by A. G. Nichols {Montreal Med. Journ., 1896), H. Koplik 
{Arch. Ped., 1896), who collected eighteen, and Vargas {Bull, offic. 
de Barcelona, April, 1897). (He counts " Jacobi among those who 



ARTHRITIS DEFORMANS. ARTHRITIS 



503 



do not mention the disease," erroneously.) Very suggestive also are 
the early changes which take place in the skin and the rest of the 
epidermoid tissues and in the muscles. The accompanying changes 
in the muscles, — a slowly progressive atrophy with corresponding 
paralysis and contracture of the antagonists, and nodes on tendons, 
the atrophy being very marked in the interossei, without reaction of 
degeneration, and with only so much alteration of electrical and gal- 
vanic excitability as is explained by the atrophy of the muscular 
tissue, — trophic changes of the nails of fingers and toes (thickening, 
fragility, and exfoliation), and those of the skin (vitiligo and 
chloasma and slight indications of scleroderma, even ichthyosis in a 
few instances * ) , appear to prove their great difference from rheuma- 
tism and their very intimate connection with the nervous system, 
which is known to influence greatly both bones and joints (S. Weir 
Mitchell, Clin. Less, on Nerv. Dis., 1897). Consequently the anti- 
rheumatic treatment, by salicylates, etc., is absolutely useless. The 
galvanic current, slowly increasing doses of arsenic administered a 
long time, protracted warm bathing at home or in Wildbad, Oeyn- 
hausen, Nauheim, Toplitz, protracted exposure to hot air of from 120 
to 150 F. (Tallerman), and judicious massage have served me best. 
Arthritis deformans is not incurable. There must be no absolute 
rest. 

Not always are many joints affected. The chronic ankylosing 
inflammation of the vertebral column, which may run a protracted 
course without an affection of the small joints, and the cases of mon- 
articular stiffness of the jaws appear to belong here. 

4. The Joints. 
Inflammations of the joints are frequent, — more so in infancy 
than in childhood. Acute cases are rare, however, in children eight 
or ten years old, who have more control over their muscles and take 
better care of themselves. Younger children are more exposed to 
traumatic injuries ; besides, not to speak of the phlebitis of the newly- 
born, there are in the earlier years distinct predisposing causes of 
joint disease in such infectious diseases as scarlatina and diphtheria. 
Syphilitic joint diseases appear in infancy and childhood in different 
forms, — as epiphysitis with effusion into the joint without synovitis 
and without suppuration ; as osteitis with effusion and with gumma- 
tous infiltration of synovial membranes and effusion; as primary 
gummatous synovitis (rarely) ; as symmetrical synovitis (mostly in 

* Curschmann in Schmidt's Jahrb., 1895, No. 8, p. 220. 



504 DISEASES OF THE BONES AND JOINTS 

the knees) in children of from eight to fifteen years, at the same period 
of life in which the interstitial keratitis of syphilis is commonly found. 
In all of these affections a thorough and protracted antisyphilitic 
treatment is required. In all joint diseases the synovial membrane, 
the fibrous capsule, and the cartilage are affected either separately 
or collectively, and the contents of the diseased cavity are either 
serous, or purulent, or fungous. Most of the latter are tubercular, 
and were known to be so long before the tubercle bacillus was dis- 
covered; indeed, as early as 1873, Koster recognized the tubercular 
nature of " tumor albus." 

The prognosis is fair when the secretion is serous. Fluctuation 
is easily recognized when the joint is superficial. It remains as " hy- 
drarthros" in chronic cases. The treatment requires absolute rest, 
and in the acute stage the flexed position of the limb — which is either 
voluntarily chosen because it relieves tension or is the result of a 
reflex contraction — must be respected. Other aids are : cold applica- 
tions and mustard-plasters ; in less urgent cases, tincture of iodine, 
pure or diluted with alcohol, once or twice daily; in chronic cases, 
a vesicatory either to its full effect or applied for half an hour only, 
and repeated daily or several times a day; later, ointments of potas- 
sium iodide and lanolin, or mercurial plaster, which may be made to 
cover the whole joint and may be changed once every few days ; two 
daily applications of iodoform in collodion (1 to 8 or 20) over the 
whole joint; compression with a rubber bandage over a proper 
pasteboard, felt, or wood splint, the latter to protect the neighboring 
large blood-vessels. Potassium iodide internally will render good 
service while the affection is of a purely inflammatory character. 
Persistent contracture must be overcome by massage, cautious passive 
movements so long as there is no pain, and forcible extension, either 
without or with anaesthesia. Massage improves the prognosis in sub- 
acute serous inflammation of the joints, also in contusions and dis- 
tortions; after the massage the joint should be immobilized, slightly 
compressed, and raised. It acts well in chronic (rheumatic) inflam- 
mation, with thickening and proliferation of the capsule. Villous 
proliferations should be broken up by manipulation and changed into 
a detritus. 

Tubercular cases have a decided tendency towards either suppu- 
ration or fungous degeneration. About the knee the abscess is some- 
times outside the capsule and permits of an incision which does not 
reach the interior. Still, a small communication with the latter is 
almost always present. The opening of intracapsular abscesses, once 
so dangerous as to be considered semi-criminal, is no longer feared. 



SURGICAL TUBERCULOSIS 505 

Repeated aspirations of the pus under aseptic precautions with sub- 
sequent injection of sterilized iodoform in oil or glycerin (1 to 5 or 
10), or in liquefied vaseline, and intra-articular occasional operations, 
such as scooping, resection, etc., with tamponing and draining, have 
reduced the dangers and are daily swelling the records of recoveries. 
General treatment to overcome the anaemic and cachectic condition, and 
particularly antitubercular hygiene and medication, are demanded in 
most cases. 

Lately (Deutsche Zeitsch. f. Chirurgie, vol. xli., July 30, 1895, 
p. 378), E. Wieland published a contribution to the treatment of 
surgical tuberculosis in childhood with iodoform injections which, 
to my mind, contains everything now known on the subject and all 
that is sound and advisable. Iodoform treatment, however, is cer- 
tainly not a panacea. Cases of tubercular coxitis, for instance, com- 
plicated with large abscesses and with perforation of the acetabulum, 
which offer great difficulties in the way of irrigation, of thorough 
cleaning out, of injections, and of compression, are liable as well to 
resist iodoform treatment as to yield unfavorable results after a 
radical operative interference. But in a large percentage of cases 
injections of iodoform emulsions, aided by orthopaedic measures (band- 
ages, stays, plaster of Paris) or by mild operative procedures, and 
last, but by no means least, by constant attention to the general health 
(air, food, clothing, and bathing), and by medicinal support with 
arsenic, creosote, or, preferably, guaiacol, yield good results. It is 
true that this treatment takes patience and time, is even apt to be ex- 
pensive, and certainly exhibits no tangible proof of a great surgical 
achievement to the impressionable lay mind ; but it is efficient, and has 
the advantage of not interfering with the growth and development 
of the limbs, which are mostly injured, and permanently so, by sub- 
jecting the epiphyseal cartilages to a radical operation. In a few 
cases the absorption of iodoform, when employed in solutions, has 
proved dangerous through a consequent toxic nephritis. For this 
reason, solutions in ether or oil are not to be recommended; for, 
after all, it is the local effect of iodoform which is aimed at, and 
not a general one. Emulsions are preferable. Krause employs a sus- 
pension of ten per cent, of iodoform in water, with the addition of 
but little glycerin and gum-arabic. 

The places to be selected for injections, according to him, are: 
for the wrist-joint, below the styloid process of the ulna; for the 
elbow, above the capitulum radii ; for the shoulder, exteriorly to the 
coracoid process; for the hip, above the trochanter major; for the 
knee, below the patella; for the ankle-joint, below the malleolus, 



5 o6 DISEASES OF THE BONES AND JOINTS 

in an upward direction. The injection into the hip-joint is made, 
according to Kiister, who has followed that method these fifteen 
years, at the interior margin of the sartorius muscle on a line drawn 
between the crossing of the femoral artery and the prominence of 
the trochanter major. That is where, in lean persons, the spherical 
head of the femur is liable to be felt, and where in coxitis visible 
or palpable swellings are not uncommon. For at this point the cap- 
sule is thinnest, and here, also, is the location of the subiliac bursa, 
which in ten per cent, of the cases communicates with the joint. As 
a trocar may hurt the cartilage, a hypodermic syringe is employed 
the canula of which has a length of from five to seven centimetres 
and a thickness of one millimetre. Kiister does not irrigate the joint, 
because in a large proportion of the cases there is either no fluid at 
all (parenchymatous synovial tuberculosis), or when present it is 
either sero-fibrinous (hydrops tuberculosis) or purulent (cold abscess). 
Neither Bruns nor Kiister believe that an irrigation with a three- 
per-cent. solution of boracic acid or another antiseptic has any better 
effect than the uncombined injection of iodoform. In the paren- 
chymatous variety from five to ten cubic centimetres (one to two 
and a half fluidrachms) of a mixture of twenty per cent, of iodo- 
form and eighty of glycerin are employed ; this operation is performed 
weekly (Bruns). In the serous or purulent variety, after the fluid 
is either aspirated or spontaneously discharged, from ten to thirty 
cubic centimetres, enough to moderately fill the cavity (two and a half 
fluidrachms to one fluidounce), are injected. This procedure is re- 
peated every two or four weeks (O. v. Biingner, Ccntralb. f. Chir., 
No. 51, 1892, pp. 1057-1064). Periarticular abscesses should be in- 
cised and scraped thoroughly before an injection is made. The same 
holds good for fungous degeneration of the capsule of a joint. Bones 
in a very diseased condition — the talus, for instance — should be re- 
moved entire. If pus cannot entirely be removed, counter-openings 
are required. At first, for the purpose of thorough cleansing and 
disinfection, irrigations may be made with a mild solution of mercuric 
bichloride (1 to 5000), to be followed for a few moments by a stronger 
one (1 to 1000 or 2000). The principle of conservatism must never 
be lost sight of. All are unanimous at present that conservative treat- 
ment is the more urgently demanded the younger the patient. Radical 
operations are indicated only when the case is one of extensive and 
protracted irremediable suppuration with progressive destruction of 
tissue. Resection, however, must not go beyond the cartilage between 
epiphysis and diaphysis. If tuberculosis be markedly developed, either 
locally or generally, it is better to amputate than to resect. Fistula? 



BIER'S TREATMENT 507 

which do not contract or shorten should be treated with strips of 
gauze dipped in equal parts of balsam of Peru and alcohol, and when 
they are very dry and indolent with (Villate's) injections, composed 
of copper sulphate 10 parts, zinc sulphate 10 parts, and distilled 
water 120 parts; or a fuchsin ointment (1 to 80 lanolin and 20 fat). 
It is particularly the knee- and elbow- joints that require conservative 
treatment, both cautiously and patiently. 

Another method of conservative treatment of tubercular joints 
has been introduced by A. Bier (Arch. f. klin. Chir., 1894, p. 306). 
Encouraged by the fact that lungs in a condition of passive hypersemia 
resulting from cardiac disease or from kyphosis have a rather pro- 
nounced immunity from tuberculosis, he advises to produce a passive 
venous congestion of the tubercular joints by bandaging the limb 
tightly below the affected joint and compressing it above with an 
India-rubber band (Esmarch). To secure a moderate amount of 
hyperemia and cyanosis, and to avoid undue pressure and oedema, 
the bandaging should be gentle, be interrupted once or twice a day, 
and not continued through the night and when there is a suspicion 
of phlegmon. Such a degree of passive hypersemia is known to give 
rise to the new formation of connective tissue and to induration. That 
hyperaemia, it is suggested, affords a certain degree of protection 
against the proliferation and action of bacilli ; it is " bactericide." 
This is also the effect aimed at by Landerer when he recommends 
cinnamylic acid, and by Lannelongue, who injects zinc chloride for that 
purpose. That such was Koch's original theory when he introduced 
tuberculin is well known. 

It is only very docile children that submit to the treatment readily. 
That is why days should be spent on playwise application of the 
method and on gaining the good will and the confidence of the 
patient. Bier continues his treatment at least three months. Mas- 
sage, formerly used simultaneously, he has discarded. He found 
his method particularly practical when employed for tuberculosis 
about the ankle-, knee-, and elbow-joints, also for the testis, less so 
for the shoulder, not at all, as yet, for the hip- joint. He found, how- 
ever, that if there was much suppuration, the limbs thus obstructed 
tended now and then to acute inflammation, lymphangitis, or erysipe- 
las. Ulcerations increased in size, but finally healed ; sometimes large 
granulations sprang up, but recovery eventually took place. Tuber- 
cular sequestra were often absorbed, and sometimes firmly attached 
to and embedded in the surrounding osseous tissue. Even tubercular 
skin was benefited by frequent dry cupping, but not to such an extent 
as joints and bones by the above treatment. Glands were not acces- 



508 DISEASES OF THE BONES AND JOINTS 

sible to the same method, except the cubital. Carcinoma, sarcoma, 
lupus, and syphilitic swellings were rather the worse for it; so was 
extensive suppuration with streptococci and staphylococci. In acute 
rheumatism the effects varied; in gonorrhceal joints, chronic articu- 
lar rheumatism with no acute exacerbations, and arthritis deformans 
they were fair. If carried out with care and perseverance, Bier's 
method sometimes yields astonishing results. (See Willy Meyer's 
report before Orthop. Section of the N. Y. Acad. Med., Amer. Med. 
Surg. Bull, 1895.) 

The treatment, however, is not always to be confined to this 
method alone. Abscesses are aspirated, if possible, in their upper part 
to avoid persistent discharge, and filled with a ten-per-cent. iodoform 
emulsion. Slight compression may follow, and the injection is re- 
peated in about a week. If there be considerable purulent discharge, 
the iodoform treatment is continued or Villate's solution (p. 507) 
employed. Under its use bone fistulse heal rapidly. If loose splinters 
be accessible, they are removed. Forcible extension by apparatuses 
under anaesthesia, tenotomy, and plaster of Paris should be employed 
in the treatment when indicated; so should passive movement, mas- 
sage, and warm baths, particularly where there is functional anky- 
losis. True ankylosis requires resection when the false position of 
the extremity becomes intolerable, for a considerable curvature of 
the lower extremity or the extension or hyperextension of the upper 
cannot be borne. That generous diet and proper hygiene and anti- 
scrofulous and antitubercular medication must not be omitted in an 
ailment which is either the result or may be the beginning of a gener- 
alized infection is self-evident. The best results of the treatment 
of tubercular bones may be expected in the calcaneum; its anterior 
portion is mostly affected because its spongy part has a scanty circula- 
tion only and its medullary part is large and soft. For the same 
reason sequestra may be found, which are rare in the other bones of 
the tarsus. As it is least connected with other bones, its tuberculosis 
remains mostly local, but may affect the adjacent tendons (Finotti). 

So far as the antitubercular treatment with guaiacol is concerned, 
I can but repeat what I said on the subject formerly. No one treat- 
ment of all forms of tuberculosis ever satisfied me to the same degree 
as has that with guaiacol. In the different varieties of pulmonary 
tuberculosis, when the destructive process was not too acute, it has 
almost invariably improved both appetite and general condition, ren- 
dered expectoration less purulent, and increased the weight of the body 
as well as improved the complexion. The more chronic the cases 
the more perceptible is the effect of guaiacol. Thus, in tuberculosis 



COXITIS 509 

of the osseous system its action is very satisfactory. The dose for 
a small child is from a drop to two or more drops, to be repeated 
three or four times a day, or guaiacol carbonate in three or four daily 
doses of from one to three or four grains each. Both of these prepa- 
rations, particularly the latter, may be combined with other drugs, 
according to indications, — preferably with arsenic in generalized tu- 
berculosis of the soft tissues, or with phosphorus in extensive inflam- 
mations of the bones of a chronic or subacute nature. 

Coxitis begins mostly in the head of the femur, and is rarely 
attended by very acute symptoms. As it is curable when recognized 
early, every case of dragging, of untimely fatigue, of favoring either 
limb, of vague pain, and of slight increase of body temperature in 
the afternoon requires careful and repeated examination. Pain in 
the knee depending on irritation of the obturator and internal saphe- 
nous nerves is not increased by pressure. Limping and apparent 
lengthening of the limb with abduction and shortening with ad- 
duction are found not to be actual, but the result of voluntary 
change of position. These conditions are overcome by rest, the local 
applications mentioned above, and conscientious extension in bed. 
At a later period, when all the symptoms of acute irritation have dis- 
appeared, extension by apparatuses and counter-extension may be 
employed for the purpose of permitting active exercise (Taylor's and 
Phelps's extension splints). When, however, the swelling increases, 
an abscess is formed, and perforation takes place, a spontaneous luxa- 
tion will often be the result, with either elongation or shortening (luxa- 
tion upward and backward with adduction and inward rotation of 
the extremity). The os ilium may perforate, or what is left of the 
head of the femur may start for the sciatic foramen, or upward, 
and all of the head may be lost by suppuration. Even in these bad 
cases partial recovery sometimes takes place. A new joint may be 
formed or actual ankylosis result from the healing surfaces joining 
one another. The size of the incisions will depend on that of the 
abscesses, and the operations on the bones on their condition. Com- 
plete resections ought to be made in as few instances as possible; 
the periepiphyseal cartilages controlling the growth of the limb require 
careful protection. 

Tubercular coxitis is eminently a disease of early age. Nearly 
fifty per cent, of the cases occur during the first decade of life, nearly 
forty during the second. One-third of all the cases remain free of 
suppuration ; of these, seventy-seven per cent, get well ; of the puru- 
lent form only forty-two. Altogether, about forty per cent, terminate 
fatally, death ensuing from tuberculosis of the lungs or of the 



510 DISEASES OF THE BONES AND JOINTS 

meninges, or from general miliary tuberculosis, amyloid degeneration, 
or exhaustion by suppuration or by sepsis. About fifty-five per cent, 
get well under conservative treatment ; still, the motility of the hip- 
joint is impaired by contraction, so that either adduction (in two- 
thirds of the cases) or abduction, with actual or apparent shortening 
or lengthening of the extremity, results therefrom. Actual shorten- 
ing depends either on retarded growth or (in the process of bone 
destruction) on displacement of the acetabulum, which is more fre- 
quent than spontaneous luxation; apparent shortening results from 
the voluntary elevation of the hip, or by fixing the extremity in ad- 
duction parallel to its fellow. 

The general rules of constitutional and local treatment hold good 
for gonitis (inflammation of the knee-joint), which is liable to be 
tubercular in perhaps a larger percentage than any other joint. De- 
formity becomes very marked at an early date, the leg is very apt 
to be luxated backward, rotated outward and in genu valgum posi- 
tion, and both pseudo-ankylosis (adhesion of the ends of the bones 
by connective tissue) and true ankylosis (solid connection of the 
cartilages or of the bones) are frequent. 

Inflammations of the ankle- and tarsal- joints are mostly tuber- 
cular. They take a slow course in most instances, and result but 
rarely in recovery unattended by deformity, unless there be timely, 
either conservative, or operative, or combined treatment, which may 
save many a foot and life. Unfortunately, constitutional tuberculosis 
is a frequent complication, and death, therefore, is not uncommon 
before even a local restitution can take place. The elbow-joint exhibits 
the same tendency to deformity and ankylosis, but is rarely the source 
of a hectic condition and of death. Early fixation in a sling and the 
application of either water-glass or plaster-of-Paris bandages are 
indispensable, while the forearm and the humerus should be placed 
nearly rectangularly. The same position must be secured for the 
foot. In coxitis and gonitis the limb ought to be kept entirely or 
nearly straight. 

Genu valgum (knock-knee) is the exaggeration of a normal dis- 
position produced by a slight depression of the external parts of the 
articular surface, mainly of the thigh. This disposition is increased 
by the rhachitical softening of the bone (in later life to an eminent 
degree by the pressure brought about by the occupation of bakers, 
waiters, saleswomen, etc.). The speedy cure of rhachitis is an essen- 
tial preventive. A plaster-of-Paris support (which ought to be re- 
newed every few weeks), made to dry while the extremity is gently 
flexed, procures a normal position while the bone is hardening under 



KNEE-, ANKLE-, AND TARSAL-JOINTS. CLUB-FOOT 511 

the influence of phosphorus, etc. The elastic length-garters, which 
have to a great extent taken the place of the circular ones, applied 
below or above the knee, must not be tense, for in that case they 
increase the external concavity. They ought to be worn on the inside 
of the thighs, or both inside and outside. In bad and chronic cases 
osteotomy is performed above the condyle of the femur (Macewen), 
also on the diaphysis of the tibia, and the bones are then allowed to 
heal in extension. Genu varum is almost always the result of a rha- 
chitical outward curvature of (and below) the epiphysis of the tibia. 
It is but rarely that the femur participates in the deformity. If it 
be noticed in time, straightening can be effected before the parts 
harden. After this has taken place, osteotomy or osteoclasy must be 
resorted to. 

Pes varus (club-foot) is often congenital. Defective supination 
is normal in the foetus, and becomes exaggerated by the pressure of 
the uterus when amniotic liquor is scanty. In many cases there is 
at birth a deformity of the talus of such a character that its neck is 
long externally and the head turned inward; also of the calcaneum, 
whose anterior process is raised and articulations somewhat dis- 
lodged. According to H. von Meyer, the posterior tibial muscle is 
always primarily affected. The paralytic variety of club-foot results 
from immobility of the extremity, caused by complete paralysis or 
by some other sickness necessitating protracted rest in bed, or from 
paralysis of the extensor muscles of the lower extremities consequent 
on poliomyelitis. The deformity is an equino-varus rather than a 
mere varus. With proper timely precaution its development may be 
avoided. 

As the articulations begin to suffer at a very early period, and 
growth is very rapid, treatment should begin at once. Indeed, the 
foot which at birth is seventy-five millimetres in length, is one hun- 
dred and seven millimetres after a year, 122.3 millimetres after two 
years, and 136.4 millimetres after three years. There is an increase 
of forty-three per cent, in the course of the first year; this increase 
is the more rapid the younger the infant. After three months the 
foot has added one-seventh part to its original length, and another 
ninth in the second quarter. Therefore, recovery from a moderate 
degree of club-foot, when treatment begins at birth, will take three 
months ; when after a year, twelve months. 

Manual correction with massage must be resorted to many times 
during the day. At night the tender foot of the newly-born bears 
quite well a pasteboard splint, well lined, and strapped with a snug 
bandage. Later, or in procrastinated cases, a plaster-of-Paris band- 



5 i2 DISEASES OF THE BONES AND JOINTS 

age, or one of water-glass, or of poroplastic felt modelled around the 
foot and lower two-thirds of the leg on its inner side will be required 
to preserve the normal position. As there is occasional anaesthesia 
of the surface, great care must be taken lest undue pressure be exer- 
cised. After the above treatment has had a satisfactory effect, 
Scarpa's, Stromeyer's, Sayre's, or any other shoe which permits of 
walking should be used. Tenotomy is required in a great many cases, 
— either of the tendo Achillis, or the anterior tibial, or the plantar 
aponeurosis, or several of them at the same time. The open operation 
of A. M. Phelps (preceded by Alfred C. Post) has gained many 
friends. He cuts all the layers of the soft parts at the sole of the 
foot successively, avoiding the ramifications of the plantar nerve, and 
occasionally incising the articulations of the talus and of the navicular 
and internal cuneiform bones. Healing takes place under the moist 
blood-clot. The paralytic muscles require persistent use of both the 
interrupted and the continuous currents. The function of the muscles 
can be improved, provided the patience both of the physician and of 
the patient is equal to the necessities of the case. Elastic straps may 
be so arranged as to sustain or replace the normal muscular function. 

Pes equinns is the result of paralysis, either local, or spinal, or 
cerebral, and is complicated with atrophy of the muscles of the calf 
and of the sole of the foot, the sole becoming concave and the toes 
pointing downward. Here also tenotomy of the tendo Achillis and 
of the plantar aponeurosis, together with the employment of elec- 
tricity and galvanism, are indicated. An apparatus is required to lift 
the anterior part of the foot, and while the patient is lying down or 
sitting up, soon after the operation, he may practise upon a band prop- 
erly attached to temporarily restore the normal position. Children 
will easily learn to look upon the exercise as play. 

Pes calcaneus in a mild form is often congenital and sometimes 
complicated with pes valgus. The desirable position is restored by 
a shoe supplied with a high heel and so constructed as to press the 
foot down. 

After Albert had accomplished, in 1877, an artificial stiffening of 
the joint, which should be considered a last resort only, by his arthro- 
desis, Nicoladoni introduced the shortening or transplantation of 
(not necessarily the same) tendons. 

To heal a talipes calcaneus with paralysis of the muscles of the 
calves, he severed the peroneal muscles behind the malleolus and the 
tendo Achillis above the heel, and joined the central ends of the pero- 
neal tendons to the stump of the tendo Achillis. Pocas, in a case of 
paralytic pes valgus, connected the tendons of the extensor hallucis 



PES EQUINUS. CALCANEUS. VALGUS 513 

longus and of the paralyzed anterior tibial. Ghillini, to supplant the 
action of the paralyzed anterior tibial muscle, cut the tendon of 
the peroneus longus near the cuboid bone, also that of the anterior 
tibial six centimetres above its insertion, and joined both by suture, 
with satisfactory result. Tendon grafting and muscle transplantation 
for deformities following infantile paralysis have been practised suc- 
cessfully. S. E. Milliken (N. Y. Med. Rec, November 28, 1896) 
reported on fourteen operations performed on nine patients. They 
were transplantation of the sartorius into the sheath of the quadri- 
ceps, the joining of the extensor hallucis longus to the paralyzed 
tibialis anticus, of the gastrocnemius to the peroneus longus and 
brevis, of the extensor digitorum communis to the tibialis anticus 
and vice versa, of the extensor hallucis longus to the extensor digi- 
torum communis, of the flexor hallucis longus to the tibialis anticus, 
and of a part of the deltoid to the tendon of the paralyzed triceps. 
Many successes have been scored since. 

Pes valgus {Hat-foot) is not infrequently congenital, the talus 
being found downward and forward. In other cases the deformity 
is rhachitical. Both to prevent and to cure it, antirhachitical treat- 
ment and temporary rest are demanded. There are also (rare) para- 
lytic cases occasioned by paralysis of the supinator muscles of the 
foot. In these electrical treatment and the subcutaneous use of strych- 
nine, together with massage of the calf and of the sole of the foot 
and stimulating embrocations and friction with cold or hot water, will 
render service. In all severe cases walking should not be permitted 
until a reasonable time has elapsed; the lower extremity should be 
raised, symptoms of vascular irritation relieved by applications of cold 
water, and a normal position should be enforced by plaster-of-Paris 
bandaging, which must be continued through weeks or months. When 
walking appears to be again permissible, the inner margin of the 
foot must be raised by thickening a part of the sole of the shoe, or 
by elevating it by springs which are elastic enough not to injure by 
pressure. I. Wolf insists upon not resting the patient at all, but 
makes him walk immediately after the application of plaster of Paris. 

From a practical point of view, the subdivision of scoliosis into 
three varieties is as follows : the first degree comprises those cases 
in which suspension of the body removes the deformity altogether; 
the second, those in which this effect is but partially attained: the 
third, such as are not influenced by it. The prognosis in the first is 
favorable; in the second it is fair when the growth of the skeleton 
is not completed ; in the third it is not good, but should not be con- 
sidered absolutely bad. It greatly depends on whether the scoliosis 

33 



514 DISEASES OF THE BONES AND JOINTS 

results from a relative or an absolute insufficiency of muscles, or 
whether it is caused by a deformity of the vertebral bodies. The 
former may be either simply local in the muscles or depend on central 
paralysis, in poliomyelitis, in Friedreich's disease, and in some cases 
of progressive muscular atrophy. The latter may be congenital, but 
is frequently the result of rhachitical softening later. In such in- 
stances a thorough antirhachitical treatment, with proper food and 
hygiene and phosphorus, must not be postponed a single day. The 
habitual scoliosis of the first eight or ten years is of merely muscular 
origin, and mostly total and universal ; the convexity generally to 
the left, and not often lumbar. This condition is found in babies who 
are persistently carried on the left arm; in school-children who rest 
the left arm on the table while the body is accommodating itself to the 
book and leans to the right ; in girls who approach the bench sideways 
and pick up their skirts under the right gluteal region. The danger 
of becoming scoliotic is particularly great in those school-children 
whose sight is defective. Those who stand a great deal and carry 
the right shoulder forward develop a right dorsal with a compen- 
satory left lumbar scoliosis. The prevention of all varieties consists 
in the avoidance of their causes. A baby must not be persistently 
carried on one arm: a mother is more apt to obey this rule than a 
nurse. The muscles must be exercised at an early age, — simple do- 
mestic gymnastics, but not overexertion ; and the habitual use of cool 
or cold washing once or twice a day, with good food and air and 
plenty of sleep on a hair mattress, are indispensable. The school les- 
sons ought not to last more than twenty or at most forty successive 
minutes ; there must not be too many of them ; there should be ample 
light from the left side while the child is studying or writing; de- 
fective sight must be corrected by glasses ; the chairs or benches should 
be supplied with a support up to the lower dorsal region of the spine. 
During school sessions a light corset may also be worn, and at night 
an apparatus to restore the equality of the two sides. Massage of 
the defective side and of the muscles in general will add to the good 
effect, and the concave side of the chest may be exercised by the 
enforcement of the habit of deep inspiration while the hand is firmly 
planted and pressed on the convexity. Systematic exercise and 
strengthening of all the muscles of the body by appropriate gym- 
nastics, particularly in well-directed institutions, are greatly to be 
recommended. 

In more obstinate cases the foot corresponding with the lowered 
hip may be raised by thickening the sole of the shoe. Volkmann 
recommended the raising of the chair or bench under the dropping 



SCOLIOSIS. KYPHOSIS 515 

hip. Sayre's corset is either worn constantly or is made detachable. 
Rauchfuss's apparatus is so constructed as to leave the defective side 
but little or not at all supported while the patient is lying down. 

The kyphosis of feeble rhachitical children requires general anti- 
rhachitical treatment. The baby must not sit up until the muscles 
have become stronger; the bed should have a hair mattress; and 
the patient must take the air while being carried either on a hair 
mattress, or in a wire cuirass, or in a tin or pasteboard or sole-leather 
mould sufficiently lined to be comfortable. As the baby grows, walk- 
ing must not be encouraged. He will rise when his bones are hard 
enough and his muscles sufficiently strong. 



XIV 

Diseases of the Car 

Malformations of the ear, both external and internal, are mostly 
the results of arrests of development, and are but rarely amenable 
to improvement by treatment. A faulty position of the auricle may 
be corrected after birth; when it protrudes unduly, bandages or 
adhesive plaster, worn for a number of weeks, will keep the organ 
in a more normal position. Obstruction of the auditory canal by 
either an epithelial or an organized membrane can be relieved ; the 
former demands a metal probe to perforate it; the latter, a cruci- 
form incision and removal of the flaps. 

Foreign bodies are common in all accessible cavities, which prove 
frequent receptacles for shoe-buttons, beads, peas, beans, etc. ; some- 
times their removal is very difficult; vegetables swell and thereby 
totally obstruct the meatus. The use of probes during examination 
is sometimes decisive in regard to diagnosis, sometimes very decep- 
tive ; the reflector is indispensable. The secretion of secondary ca- 
tarrh must first be removed by syringing and wiping; pincers will 
remove a body which is not tightly incarcerated ; a Daviel spoon, or 
the blunt end of a hair-pin bent upon itself, or a sharp spoon is often 
required for peas and beans. While the attempts at removal are going 
on, the ear ought to be frequently injected with warm water to expel 
shreds and blood and to facilitate inspection. Before the operation 
is begun, a cocaine solution may be instilled into the ear. A spray 
of ether may be demanded, and in urgent cases anaesthesia by chloro- 
form; for, the extraction of a foreign body being paramount, even 
pieces of bone have to be removed sometimes to render its expulsion 
possible. 

Living bodies, such as insects, will die in water, oil, alcohol, or a 
two-per-cent. solution of carbolic acid. Dried secretion, or ceru- 
men, is softened by filling the ear with oil or glycerin and syringing 
forcibly with soap and water. The after-treatment may demand all 
the requisites of the therapy of inflammation, — rest, cool and dis- 
infectant applications, erect posture, and narcotics. 

Otitis externa (inflammation of the external auditory canal) is 
the result of irritation by foreign bodies or by clean or dirty finger- 
nails, brushes, and sponges, also of the frequent use of ear-spoons, 
or of exposure to a high wind or draught ; or it may depend on 
5i6 



EAR. FOREIGN BODIES. OTITIS EXTERNA 517 

eczema which extends inward from the neighboring surface. Gono- 
cocci and tubercle bacilli have been met with in the external ear, 
diphtheria not infrequently; dirty bathing water is probably a more 
common cause of ear disease than is generally supposed. Now and 
then external otitis complicates internal, particularly in infectious 
diseases such as measles and scarlet and typhoid fevers. The gen- 
eral disposition to scrofula — that means to subacute or chronic inflam- 
mation of the tissues with rapid disintegration of the surface epithe- 
lium and insufficient tendency to reparation — is a frequent factor in 
the production of external ear disorder, and requires constitutional 
treatment. Preventive measures are indicated by the causes enumer- 
ated above. Foreign bodies must be looked for and, if present, 
extracted. 

The three forms of external otitis are the erythematous, the ca- 
tarrhal, and the phlegmonous (including the furuncular). The first 
exhibits a general redness, and produces scales rather than secretion. 
An occasional application of lead wash, or lead ointment, or zinc 
ointment, or bismuth carbonate, finely powdered, will be all that is 
required in the average cases. Where the redness is marked and 
angry, with a good deal of itching, the ointment should contain five 
per cent, of cocaine; or a watery solution of cocaine hydrochlorate 
(from two to six per cent.) or a fresh suspension of adrenal substance 
in water (1 to 10) may from time to time be brushed over the sore 
surface. 

The catarrhal form of external otitis is by no means a uniform 
or always a mild affection. There may be pain, also secretion of a 
simply catarrhal or of a malodorous (fat acids) or cheesy nature. 
Erosions, ulcerations, and swelling of the neighboring lymph-bodies 
are quite common. The integument is sometimes greatly swollen 
and now and then granulating; below and behind polypoid excres- 
cences the bone may be affected; through the defective ossification 
(sometimes persistent) anteriorly and inferiorly, fistula? may form 
in the parotid region and even in the maxillary joint, and pus may 
find its way along the incisura Santorini through the cartilaginous 
floor of the meatus. The drum membrane is frequently affected. 
Every form of myringitis is met with, from a slight hyperemia to 
thickening and turbidity of the membrane, even to perforation. Thus, 
there is every reason for early and persistent treatment. In the in- 
terest of examination, the speculum must not be used at first, except 
in older and very docile children; it annoys, pains, and frightens, 
and is seldom as useful as in advanced age because of the horizontal 
position of the young drum membrane, only part of which, at best, 



518 DISEASES OF THE EAR 

can be seen. The secretion must be removed by syringing both 
frequently and forcibly (but the current must not be directed to 
the drum membrane) while the head is inclined so as to allow the 
instantaneous egress of the fluid. The injection fluid may be warm 
water, soap and water, salt and water (6 or 7 to 1000), or mild as- 
tringent solutions of lead acetate, zinc sulphate, tannin, or alum ( 1 or 2 
to 200) ; or the secretion may be removed by tufts of absorbent, or 
borated, or salicylated cotton, which are held tightly in a pair of 
pincers and not rubbed hard against the wall of the canal. A satu- 
rated solution of boracic acid (four per cent.) is both mild and 
slightly disinfectant. Boracic acid finely powdered may be thrown 
in so as to fill the canal after it has been thoroughly dried. When 
the renewed secretion has liquefied the powder, after a few or many 
hours, they are both removed by cotton or by injections, the ear 
thoroughly dried, and boracic acid introduced again as before. Mer- 
curic bichloride (1 to 5000) injections may be given several times 
a day, mainly when there are much hyperemia and infiltration, in any 
of the varieties of external otitis ; warm fomentations of the same 
solution should be made persistently. Two daily applications of car- 
bolic acid in glycerin (1 to 10 or 20) have also been recommended; 
I believe they frequently irritate and fret the surface. Polypoid 
granulations have been removed by ligature. Chromic acid is liable 
to deliquesce so much, even when used carefully and in small quanti- 
ties, as to endanger the drum membrane. The solid stick of silver 
nitrate is safer, and requires for neutralization, after application, only 
a salt-water solution. A daily touching with liq. ferri perchlorid. 
or liq. ferri subsulphat. is very effective and quite safe. Biedert 
recommends hydrargyrum sozoiodolate. In external otitis leeches 
are seldom required, and then only when there is an excess of swell- 
ing. To relieve local pain and tension, cocaine solutions act better 
than do those of morphine. The oleate of morphine irritates the sore 
surface. Internally, a dose of morphine or some other opiate, or 
chloral, may become necessary. The patient must be kept in a semi- 
recumbent or almost erect position, on a cool pillow, in every catarrhal 
or inflammatory condition of the ear. Cases of external otitis with 
copious secretion, complicated with or dependent on eczema, are 
greatly benefited by one or two daily applications of a small quantity 
(well rubbed in) of mercuric bichloride in lanolin (1 to 300 or 500). 
In obstinate cases of eczema a solution of silver nitrate (1 to 10 or 
50) may be brushed over the parts once every few days, or Lassar's 
paste may be used (zinc oxide and amylum aa. 25, salicylic acid I, 
white vaseline 50), which need not be removed when a new application 



POLYPUS. OTITIS MEDIA 519 

is made; or an ointment containing pure tannic acid and glycerin, 
aa 4 parts, which are mixed thoroughly, and to which are added 
fat 30 and carbolic acid 0.3 parts. 

The phlegmonous form of external otitis is mostly recognized 
with facility; the pain is intense, the swelling marked, more or less 
local, circumscribed, and red. Before an incision — which ought to 
be made in time — appears advisable, applications of solutions of 
hydrargyrum bichloride (1 to 5000 water) are better than warm 
fomentations. As stated, incision must be made soon and will re- 
lieve quickly. The furuncular form demands at once either an in- 
cision or carbolic acid treatment. Both should be preceded by local 
cocaine or ethyl bromide anaesthesia, for the pain may be intense. 
The incision must be as thorough as in a furuncle of any other region. 
It may often be substituted by a thorough application of concentrated 
carbolic acid. If applied early, a single (or repeated) application 
will prove effective. As its action is quite local, when used carefully 
there is no danger. If the furuncle be pointed and the surface ex- 
cessively painful, the acid ought to be introduced into the centre of 
the swelling by means of a slightly curved probe. 

Accompanying myringitis is apt to improve after its cause — the 
otitis externa — has been removed. A vesicatory or tincture of iodine 
on and about the mastoid process is helpful. Direct injury of the 
drum membrane by cold water or salt water during bathing can be 
averted by a wool tampon. 

Otitis media, both the catarrhal and the purulent varieties, is a 
very frequent disease in infancy and childhood. It is asserted by 
some that it is found in seventy per cent, of all nurslings, which is 
an exaggeration. The great vascularity of the mucous membrane of 
the middle ear furnishes a ready disposition. Even in the middle 
ear of the newly-born accumulations are met with which either con- 
stitute or dispose to otitis. According to some, the masses frequently 
encountered consist of detritus developed from the fcetal epithelial 
covering; others accuse aspiration during and immediately after 
birth; some attribute pathological changes to cedema produced ex 
vacuo, the vacuum being due to the sudden separation of the mucous 
membranes formerly closely adjacent to each other. Infants have a 
large, short, more horizontal Eustachian tube, with a funnel-shaped 
pharyngeal aperture; thus infectious material of the common erup- 
tive fevers, streptococci and staphylococci, the bacilli of a diphtheritic 
rhinitis, and even gonococci find easy access. Most frequent are the 
diplococcus Fraenkel and the staphylococcus pyogenes albus ; strepto- 
coccus impairs the prognosis. On the other hand, pus has an easier 



520 DISEASES OF THE EAR 

egress from the cavity, even during the sucking movements; that 
is why otitis media may run its full course without apparent local 
symptoms, and why obscure fever, sepsis, or atrophy should rouse 
the suspicion of occult ear trouble. Perforation of the drum mem- 
brane does not occur in such cases. In lobular pneumonia otitis 
media is quite frequent, still more so in croupous pneumonia; in 
scarlatina, also in measles and typhoid fever, it may be very severe. 
All the varieties of nasal, pharyngeal, and naso-pharyngeal catarrh, 
also adenoid vegetations and hypertrophied tonsils, are known to be 
frequent causes of middle-ear disease. Vehement spells of whooping- 
cough, forcible medicinal or other injections into the nares, and vio- 
lent sneezing, coughing during pneumonia, vomiting, or finger contact 
during gastro-enteritis are apt to carry foreign material into the 
Eustachian tube and middle ear, particularly when the uvula is con- 
genially split (bifida), and still more so when the hard palate is 
fissured or when there are adenoids which impede pharyngo-nasal 
ventilation ; for in such a case the levatores palati have no support 
and the muscles of the tube are insufficient and atrophied. 

Preventive treatment has a wide scope. The number of cases 
of otitis media — according to Schwartze, twenty-two per cent, of all 
diseases of the organ of hearing are purulent forms of middle-ear 
disease — is as significant as its causes are manifold. Nasal, post- 
nasal, and pharyngeal catarrhs must be attended to in their incipiency. 
Regular attention to the nose of infants would prevent much disease 
and many calamities. Indeed, defective hearing is more common than 
we suspect. Bezold found (1886) that of nineteen hundred and 
eighteen school-children, twenty-five per cent, had but one-third and 
eleven per cent, but one-fifth of normal hearing distance, and his 
statements have been amply confirmed by many more recent ob- 
servers. Most cases of perforation of the drum membrane, chronic 
suppuration, abscesses in the mastoid process, permanent paralyses 
of the facial nerve, and cerebral abscesses can be prevented by treat- 
ing and curing the origin and fountain-head of the future distress. 
The hypertrophied mucous membrane of the nose must be reduced, 
adenoids removed, and enlarged tonsils resected in time. The in- 
terior of the nose, at least of every infant or child with a tendency 
to nasal or pharyngeal catarrh, ought to be washed — irrigated — at 
least once a day, according to known principles (p. 410), but very, 
very gently. Gentle insufflation of the nares will clear the cavities 
of mucus. It may be done by a Politzer apparatus (no simultaneous 
deglutition is required) or by blowing into a soft-rubber tube intro- 
duced into one nostril, while the other is kept open. There is better 



OTITIS MEDIA 521 

reason, from the point of view of danger to health or life, for washing 
the inside than the outside. 

A child with an acute attack of middle-ear disease ought to be 
in bed, the head raised. The symptoms are not always urgent or 
easily recognized. In the very young the large size and shortness 
(p. 519) of the tube facilitate the exit of the internal secretion into 
the throat, so that the drum membrane is not annoyed and pain from 
internal pressure and irritation is insignificant in many instances. 
Careful examination, however, will leave a doubt as to the actual 
seat in few cases only. A mild antipyretic, a small dose of a nar- 
cotic, or a purgative will ameliorate the symptoms. In the very be- 
ginning the Eustachian tube ought to be treated by inflation (Politzer) 
very carefully, if at all; older children, who can be taught the use 
of Valsalva's method, must be warned against its excessive and vehe- 
ment employment. When the acute stage has passed, both are mostly 
indicated. The severe pain may be relieved by a cocaine solution 
(2 to 10 or 100) instilled into the ear, also by one or more leeches to 
the mastoid process of the affected side, in most cases but one side 
being diseased. In mild ones tincture of iodine alone will suffice. 
When the drum membrane is red, a cloth moistened with a solution 
of hydrargyrum bichloride in water (1 to 5000), applied to the ear 
and frequently repeated, will, after getting warm, do equally as well 
as the most favored warm poultices. When secretion of mucus or 
pus is increasing inside, the posterior half of the drum membrane is 
pushed out first, afterwards the anterior; between the two, particu- 
larly in older children, the hammer can be distinguished. A spon- 
taneous perforation is apt to form in the anterior portion, but the 
presence of a white discoloration does not always indicate pus. When 
the protrusion of the membrane is very marked, an incision should 
be made, mostly posteriorly and inferiorly. The general opinion of 
experts, however, is no longer in favor of indiscriminately early 
operation ; still, when it is performed, the incision ought to be suffi- 
ciently large. Pus is then expelled by inflating through the nares 
(Politzer), and wiped out or carefully syringed out with a warm solu- 
tion of table salt or of boracic acid (3 or 4 to 100) . The patient should 
rest on the diseased side. Boracic acid is then used as described in 
the rules laid down for its application in external otitis, or the canal 
is gently syringed with a mild solution of hydrargyrum bichloride 
(1 to 5000), or of an astringent, — zinc sulphate (1 to 500). To 
what extent, during all this time, narcotics are to be used, or whether 
anaesthesia, local or general, ought to be employed, depends on the 
individual case and the judgment of the practitioner; also whether 



522 DISEASES OF THE EAR 

an antiscrofulous or antisyphilitic treatment (the latter but rarely in 
children) be demanded. Chronic discharges require politzerization 
frequently, though cautiously, and the use of boracic acid and astrin- 
gents; secondary polypi, treatment similar to that detailed above. 

The secondary affections of the mastoid process demand leeches, 
ice, and tincture of iodine; where there is oedema, warm poultices 
and a deep incision. Abscesses of the mastoid process and of the 
brain require timely operation by an expert hand. The general rules 
laid down by Troitsch are still valid. Cerebral affections due to 
ear disease are, when originating in the external meatus and the 
temporal bone, in the transverse sinus and the cerebellum; when in 
the middle ear, in the cerebrum; when in the vestibule and cochlea, 
in the medulla oblongata. 

According to many, the antrum should be opened and cleaned out 
for the purpose of discharging pus both from the antrum and the 
middle ear. In that way secondary operations are avoided. Contrary 
to this general practice, A. Politzer expresses the belief (Text-Book, 
4th ed., 1901) that it is sufficient to open the abscess and to remove 
its osseous wall, as far as it is softened and covered with granulations, 
without opening the antrum. The latter operation he recommends 
only when the wall between the empyema and the antrum is thor- 
oughly softened, or when there are symptoms of an epidural or a 
cerebral abscess. 

Operations require especial knowledge, dexterity, and caution when 
made on infants and young children. There are no mastoid cells yet 
(H. Knapp, Jour. Amer. Asso., February 23, 1901), but a pneumatic 
cancellous tissue in the base of the squama ; that is why abscesses are 
found above rather than behind the ear. Besides, between the bones 
there is sutural substance ; the roof of the middle ear near the third 
temporal lobe is in part membranous. 

In my opinion, one of the most important additions to modern 
surgery is our knowledge of the operative accessibility of all the 
spaces and nooks of the middle ear, as taught by Schwartze, and of 
the epitympanic part, by Zaufal, in all cases of chronic suppuration 
of the middle ear accompanied by sensitiveness or suppuration on 
the surface of the mastoid process, or by fistulse, with osseous stenosis 
of the meatus and facial paralysis ; of middle-ear disease exhibiting 
cerebral symptoms, with or without persistent fever, though there 
be no external inflammation ; also in cases of cholesteatoma of large 
size, with alarming cerebral symptoms during the operation, particu- 
larly while injections are being made, or in those in which sequestra 
or foreign bodies must be removed, mainly when they give rise to 



DEAF-MUTISM 523 

brain symptoms; and, lastly, in cases of profuse ichorous secretion, 
or of actinomycosis, or of tuberculosis of the middle ear. 

Deaf-mutism is rarely a primary affection of the organ of hear- 
ing, though arrests of development and the results of fcetal inflam- 
mations are not uncommon. It is also found in many instances of 
cretinism. It would be better in a large percentage of cases to assign 
it a place in connection with diseases of the nervous system, for most 
of both the congenital and the acquired cases result from cerebral 
affections. It is not often hereditary. If more extensive statistics 
prove its (very doubtful) dependence on consanguineous marriages, 
a wiser social hygiene can be made to act as a preventive. Alco- 
holism of the parents is a cause, and society and the state, with 
its organization of ignorance and disorder, are responsible for so 
much of deaf-mutism as is not unavoidably pathological. About 
half of all the cases are acquired, some even after children commence 
to talk, the majority of them through cerebral and cerebro-spinal 
inflammation. According to Biedert, fifty-five per cent, are of that 
class, twenty-eight per cent, depend on acute infectious diseases (ty- 
phoid, scarlatina, and diphtheria, also variola and measles), 3.3 per 
cent, on traumatic injuries, and 2.5 per cent, on ear affections. Thus 
many of the congenital cases and most of the acquired are preventable. 
The treatment must be directed to so much of pathological change in 
the brain, the acoustic nerve, or the ear as is still accessible to the 
influence of either remedial or operative interference. Chronic 
(mostly interstitial) inflammations of the brain should not be given 
up as incurable so long as mercury and the iodides have not had suffi- 
cient opportunity to show their absorbent powers during a protracted 
administration. External and internal otitis, naso-pharyngeal catarrh, 
hypertrophy of the tonsils, and adenoid vegetations should be attended 
to in time, though these affections appear ever so slight. 



XV 

Diseases of the Eye 

Malformations of the eye are of different variety and gravity. 
Some cannot be corrected, such as cyclopia, microphthalmia, and 
albinismus; some need no correction, like the common (vertical) 
form of coloboma of the iris, or the congenital atresia of the pupil. 
The latter consists in the persistency of a part of the pupillary mem- 
brane originating from the posterior aspect of the lens, and, if still 
extant after birth, disappears slowly. Others require, and are cor- 
rected by, operations. Epicanthus — an abnormal accumulation of 
cutis near the root of the nose — may be removed by an operative pro- 
cedure, in the event of its not gradually disappearing spontaneously. 

Neoplasms of the eye and eyelids are not frequent in infancy and 
childhood. Congenital ncevi of every variety, however, are not un- 
common. Very superficial ones on the eyelids should be kept under 
observation. When uniform and rather pale, they are liable to heal 
spontaneously. When a net-work of enlarged blood-vessels is found 
on the lids or conjunctiva, there is often a central point the com- 
pression of which by means of a silver probe empties all the neigh- 
boring branches. This centre ought to be destroyed by a single 
application of the thermo- or galvano-cautery, or by a trace of fuming 
nitric acid, or by running a sterile silk ligature underneath and tying it. 
When they form small or large tumors (sometimes only dilated blood- 
vessels, at other times angiomata cavernosa), in most cases the actual 
cautery is easier and safer than the knife. The cautery must be used 
carefully and sparingly, — too little rather than too much, according 
to rules detailed above, — and always with a view of avoiding a con- 
secutive ectropion. 

Dermoid cysts are found on the lids, inside; also on the eye- 
ball; even in the orbit, from which their removal is rather difficult. 
They must be enucleated when the diagnosis is undoubted. They have 
been mistakenly diagnosticated in cases of encephalocele of the inte- 
rior angle of the eye. 

Lipoma is very rare, still more so than cystic ercus cellulose?. A 
few instances have been reported in which this cystic degeneration 
of the ovum of the tsenia solium was found in children in the posterior 
chamber and under the skin of the lid. 

Chalazion (not always tubercular, as has been asserted) is a 
524 



EYE. MALFORMATIONS. NEOPLASMS 525 

mucous cyst in the tarsal cartilage, with a tendency to induration. 
The eyelid is turned over, the small tumor incised, its contents scraped 
out, and iodoform applied once. As the wound is covered by the lid, 
it heals rapidly. 

Glioma of the retina (Beer's amaurotic cat-eye) develops rapidly. 
Its vascular, sometimes red and bleeding, surface distinguishes it 
from suppuration of the vitreous body. It must be enucleated at once, 
as it is liable to grow rapidly in every direction. 

Syphilitic gummata have been observed in some cases of retarded 
syphilis. They exhibit the symptoms of iritis, and require an anti- 
syphilitic treatment. 

Tubercles of the iris are, fortunately, rare. They give rise to 
an incurable chronic iritis and necessitate enucleation of the eyeball. 
Tubercles of the choroid are sometimes observed in the incipient, 
sometimes in the advanced stage of tubercular meningitis. They are 
not considered amenable to successful treatment. But a case of tuber- 
cular meningitis with tubercle of the choroid was described lately. 
It recovered. 

Foreign bodies hidden under the eyelids must be removed speedily, 
for conjunctivitis will immediately follow their presence. They are 
often washed out by the copious secretion of tears. The lower eyelid 
may easily be turned out and the corresponding portion of the conjunc- 
tiva inspected. The upper requires turning up, which is more difficult 
because of the resistance of the child, but easier than in an adult, 
on account of the greater motility of the skin of the young eyelid. 
To facilitate inspection, the eye may be gently pressed backward into 
the orbit. The body, when seen, is removed by pincers, a fine sponge, 
a piece of gauze, or wiped off in the direction of the nose. In case 
of necessity, anaesthesia may be procured by a drop of a two-per-cent. 
solution of cocaine. This is indispensable when the foreign body 
is in the cornea and demands instrumental removal. If it be iron, 
a strong magnet will remove it ; when it is located externally, with- 
out, when in the deeper tissue, with, a previous operation. The 
danger connected with foreign bodies entering the eyeball, and the 
indication for immediate, or delayed, or no operation depend on 
the condition of the foreign body, which may be aseptic and not in- 
jurious, may irritate mechanically or chemically, or be infectious. 
As a general rule, the foreign body is readily recognized in the ante- 
rior chamber, the iris, or the lens, and should be removed immediately 
according to the rules laid down in ophthalmological works. 

Injuries of the eye by puncturing, cutting, blows, etc., require 
absolute rest, the removal of foreign bodies, the application of ice, 



526 DISEASES OF THE EYE 

of atropine solution (eserine when the wound is peripheric), and 
gentle pressure. Bad cases of laceration and destruction are either 
irremediable or require special, perhaps operative, treatment. 

Lachrymal stenosis is apt to correct itself with the development 
of the nose. Probing under ether has been recommended, and an 
astringent wash for the conjunctiva, with massage of the sac. 

Burns should be treated on general principles. The effect of 
acids is best counteracted by copious irrigation with water and cooling 
applications afterwards; of lime, by oil (not by water), the careful 
removal of the foreign body, and ice applications. 

The eyelids suffer from blepharitis mostly in scrofulous children, 
in whom dust, smoke, and infections of all kinds are apt thoroughly to 
influence the superficial tissues. It often accompanies eczematous 
eruptions of the head and face, and is frequently carried by the fin- 
gers. Therefore, soap and water, a nail-brush, and cutting the nails 
short are good preventives; so is the successful treatment of the 
head and face. The blepharitis and conjunctivitis of measles require 
no special local treatment ; the common forms do well with zinc 
ointment, or one of the yellow oxide of mercury with vaseline 
( i to 50 or 100). The secretion must not be permitted to get dry. 
Hard crusts are dissolved by a warm solution of sodium carbonate 
(1 to 100 or 200) or by frequent washing with soap and water. Grave 
cases demand epilation of the eyelashes, every one of which — so far 
as required — must be caught singly and drawn out slowly enough 
to secure removal of the entire hair. Ointments and solutions of 
lead it is best to avoid, for complications with corneal erosions, grave 
or slight, are very frequent in affections of the eyelids and conjunc- 
tiva, and even the slightest ones may be indelibly stained by lead 
salts. 

Both the integuments and the connective tissue of the eyelids 
being of loose structure and expansible, cedema is quite frequent. 
Insect bites are mostly diagnosticated by their circumscribed and 
pointed appearance ; cardiac and renal diseases require their own 
diagnoses and have their own indications ; so has hydrsemia from 
whatever cause, besides the indications for the administration of 
iron, quinine, or arsenic. 

The conjunctiva is very liable to be affected by medicinal and 
poisonous agents. According to Silberman, anilin, potassic chlorate, 
and corrosive sublimate produce thrombosis ; pungent gases, con- 
junctival hypersemia and conjunctivitis ; antipyrin, urticaria of the 
eyelids ; copper arsenite, redness and corrosion ; hydrogen arsenide, 
a brownish-red or icteric discoloration ; potassium bromide, simple 



BLEPHARITIS. CONJUNCTIVITIS 527 

or phlyctenular conjunctivitis, without, however, influencing the 
blood-vessels of the interior; chrysarobin, a local inflammation; 
coniine, a burning sensation ; ergotin, hemorrhages ; potassium 
iodide, inflammation; iodoform, when applied locally, an erysipela- 
tous tumefaction; and sodium salicylate, oedema and a bluish ex- 
anthema; in larger doses, tumefaction and vesicular eruption. Still, 
cases of conjunctival disease depending on these agents are compara- 
tively rare. 

Microbes are common in catarrhal conjunctivitis. In the newly- 
born cocci and diplococci are frequent (p. 107), in the adult diplo- 
bacteria. 

In a number of cases of conjunctivitis the conjunctiva of the 
bulbus does not participate extensively. Common forms of fevers, 
also whooping-cough and principally measles, are among the causes 
of acute conjunctivitis. Sometimes there is but little redness; the 
lids are thickened and stiff with oedema. In other cases there is plenty 
of mucus, sometimes purulent, now and then with a tendency to 
coagulation, but not to such a degree as to render difficult the differ- 
ential diagnosis from diphtheria of the eyelids. The mucous secre- 
tion must be wiped off with absorbent cotton or a moist cloth, a three- 
per-cent. boracic acid solution should be applied or instilled, and 
cold water employed at intervals of from one to ten minutes ; chlo- 
rine-water, if obtainable fresh (a teaspoonful in a glass of water), 
should be used for applications ; if the surface secretes much, corro- 
sive sublimate ( 1 to 4000 or 5000) . If the secretion be purulent, silver 
nitrate, 1 part in 100 or 500 parts of distilled water (black bottle), 
must be applied once a day, best with a brush, and washed off with 
pure water. A high degree of congestion, with phlyctenular erup- 
tions, — sometimes unilateral only, not infrequently combined with 
blepharitis, — demands persistent application of cold, best by keeping 
a number of small pieces of cloth on a lump of ice and applying them 
at short intervals until they begin to get warm. Atropine sulphate 
(1 to 200 or 500) should be instilled once or twice a day, and the lids 
kept at rest. To hold them immovable, if the patient be very young, 
a layer of absorbent cotton should be covered with, or slightly soaked 
in, collodion and applied after the eye has been wiped dry. Later an 
ointment of the yellow precipitate of mercury (1 to 50 or 100), or 
calomel finely powdered, may be employed once a day. 

Chronic conjunctivitis presents in many cases few symptoms only. 
The superficial hyperemia does not always correspond with the burn- 
ing sensation often complained of, and the mucous secretion is but 
trifling and collects mostly in the inner angle of the eye. Overexertion 



528 DISEASES OF THE EYE 

of school-children, particularly of those who are hypermetropic or 
astigmatic, diseases of the nose of a catarrhal or ulcerous nature, 
indigestion and constipation, anaemia, scrofulosis, or trichiasis, are 
just so many causes and require the appropriate causal treatment, both 
medicinal and hygienic, change of air (country), and cool and cold 
bathing. These measures often suffice to relieve even secondary dis- 
orders of the lymph circulation, which is easily disturbed. Like the 
orbits, which discharge tfieir lymph-ducts into the deep facial lymph- 
bodies, the lids and conjunctivae are connected with the glands of 
the aural and submaxillary regions. The medicinal treatment is dis- 
infectant and astringent; the remedies must be changed from time 
to time. Zinc sulphate ( I to 250 or 500) with or without cocaine muri- 
ate (1 or 2 to 100), in more protracted cases ointments of zinc or 
copper sulphate (1 to 100 or 150), solutions of boracic acid (3 to 100) 
or of sodium carbonate ( 1 to 100 or 200) , in suppurating cases a daily 
brushing with silver nitrate (1 to 250 or 1000), combined with scru- 
pulous cleanliness and avoidance of vascular stimulants, will meet all 
indications. 

The chemosis of scleral conjunctivitis does not require any addi- 
tional applications ; mild astringents and rest will suffice. Rubbing, 
constipation, and coughing result in hemorrhagic discoloration (gen- 
eral blueness or extravasations) which requires rest and cool (or 
warm) fomentations. 

Diphtheritic conjunctivitis cannot readily be mistaken. The in- 
filtration is hard and the pseudo-membrane not removable. There 
is no secretion; indeed, the eye is dry to such an extent that the 
pressure of the exudation alone ulcerates the cornea. Absolute cau- 
tion in every case of — particularly nasal — diphtheria, and covering 
the healthy eye, when (as usual at first) but one eye is affected, 
with a cotton and collodion application, aided by more cotton and a 
bandage, are indispensable. Thorough and speedy mercurialization 
and antitoxin are indicated. Papayotin (1 to 5 or 10 of water and 
glycerin), not to be substituted by " papoid," may be applied every 
hour. Silver nitrate deserves no recommendation. Chlorine-water, 
carefully applied while the eyelid is kept away from the eyeball, 
whenever that is possible, may render good service. Ice must be 
applied carefully and persistently. 

Most cases of gonorrhceal conjunctivitis are contracted during 
birth from the gonococcal discharge of the maternal vagina; others 
through handkerchiefs, towels, fingers, or bathing water. Its treat- 
ment has been discussed (p. 107). 

Trachoma, possibly of a microbic, surely of a specific character, 



TRACHOMA. KERATITIS 529 

consists of granular deposits and proliferation of cells which crowd 
upon the normal tissue and render it atrophic. Its duration is long; 
its treatment must be persistent. The acute attack, or stage, re- 
quires daily brushing with silver nitrate (1 to 100), and washing off 
with water when the first effect of the caustic becomes visible. The 
subacute cases demand a daily (or less frequent) application of 
the copper sulphate stick. The granulations may also be scarified, 
scraped out, or squeezed out, — an old operation successfully re- 
established by modern surgery. Many cases do well with a daily 
application of one part of mercuric bichloride in one thousand 
parts of distilled water. The conjunctival duplicature, which is 
the pet seat of trachoma, has been excised to get rid of a large 
part of the diseased masses at once. For domestic treatment, 
an ointment of copper sulphate and vaseline (1 to 100), with or 
without cocaine muriate, will prove beneficial. A similar treatment, 
somewhat modified and diluted, is applicable to what is described 
as granular conjunctivitis, which probably is in no case anything but 
a mild form of trachoma. Follicular conjunctivitis is probably of 
the same nature in many cases ; usually it is described as an inflam- 
mation of the (microscopically small) glands of the conjunctiva. 
The follicles are in rows near the margin of the eyelids. It is compli- 
cated with, or depends on, the presence of foreign bodies, of nasal 
disease, or of other varieties of conjunctivitis, and is not infrequently 
found in large numbers in families and in schools. The treatment 
is milder than that of the previous forms, — rest, washing, boracic 
acid solutions, astringents. 

Keratitis, beginning with a small vesicle, which is mostly not 
observed, and rapidly terminating in a superficial ulceration, is fre- 
quently met with in " scrofulous" children, who, besides, suffer from 
affections of the mucous membranes of the nose, lips, and ear, from 
eczema, glandular tumefactions, etc. Some patients are rickety. To 
overcome the spasm of the conjunctiva, cocaine is often required to 
facilitate examination; for that purpose the dipping of the head 
into cold water, a popular remedy for photophobia, is probably not 
convenient. The constitutional disorder must be combated by cleanli- 
ness, fresh (country) air, bathing, plain and nutritious diet, quinine in 
small, iodide of iron in proper doses. Potassium iodide in small doses 
(from one to two grains), three times a day, given for a long time, is 
very successful in many cases. The room must be kept moderately 
dark and the eye protected by a shield. Good local applications are 
chlorine-water diluted in from twenty to one hundred parts of water, 
corrosive sublimate (1 to 5000), boracic acid (3 to 100), atropine 

34 



530 DISEASES OF THE EYE 

sulphate solution of one-half per cent., or cocaine muriate solution of 
two per cent, (the last two occasionally in combination). When the 
ulceration is near the corneal margin, eserine is recommended in place 
of atropine; but it is advisable to remember that it produces a con- 
gestion of the iris and may predispose the latter to be drawn into 
the morbid process. Old cases will do well with occasional (one 
every day or two days) gentle applications of silver nitrate (i to 200 
or 500) or (particularly when the conjunctiva is pale) of finely pow- 
dered calomel ; this latter has always been highly recommended, and is 
useful, if persistently employed through weeks and months, when 
turbidity of the cornea remains behind. Old cases with defective 
power of reparation will do well when the lids and eyeball are gently 
kneaded with an ointment of the yellow precipitate of mercury (1 
to 50). In many instances some of these remedies will act better 
than others; alternation is often required. A simple ulceration, 
no matter what application is employed, will heal better, or best, 
by avoiding friction of the eyelids ; they ought to be immobilized 
by cautious bandaging, which may be removed to make the demanded 
local applications. Under the bandage a cloth wet with a solution 
of corrosive sublimate (1 to 5000) or boracic acid (3 to 100) will 
prove quite acceptable and beneficial. Suppurating ulcerations lead 
to hypopyon and perforation. They require, besides atropine, or 
eserine when near the margin, occasional applications of corrosive sub- 
limate (1 to 2000) or silver nitrate (1 to 100). Biedert recommends 
cocaine and scraping or burning of the abscess. According to him, the 
main obstacles in the way of speedy recovery are : complications with 
conjunctivitis, blepharitis, nasal affections, stenosis of the lachrymal 
duct and blennorrhcea of the lachrymal sac (but rarely its congenital 
obstruction), and blepharophimosis with photophobia and rhagades. 

Parenchymatous or diffuse keratitis is a peculiar variety. The 
turbidity and thickening of the two cornea? (the process being bilat- 
eral) are extensive, not always uniform, often disseminated, and com- 
plicated with considerable vascular injection on and around the cor- 
neas and with synechia of the iris. Very many cases of this variety — 
according to some, the vast majority; ninety-six per cent., according 
to Parinaud; thirty per cent., according to Siklossy — are the results 
of syphilis, either hereditary, or acquired, or retarded hereditary. 
They require persistent antisyphilitic treatment with potassium iodide 
(and mercury). Scrofula, rhachitis, malaria, and arthritis are also 
charged with producing this form. It is certainly true that iodine and 
mercurial treatment are not always successful. Some cases are bene- 
fited by sodium salicylate. Atropine is useful in all. 



KERATOCONUS. IRITIS 531 

In neuroparalytic keratitis both the conjunctiva and the cornea 
are deprived of sensibility, the lids do not move, the eye is kept open, 
the cornea is dry {xerosis) and may undergo softening (kerato- 
malacia), with the result of either perforation or incurable turbidity 
and local thickening. It is observed in severe infectious fevers, par- 
ticularly during the unconscious state of typhoid, and in the coma 
of encephalitis. These results are not often met with for a long 
time in succession, for most of the patients die of the original disease. 
They have also been noticed during and after frontal and conjunc- 
tival herpes zoster. In all these cases the eyeball must be moistened 
with salt and water (6 or 7 to 1000) and the lids closed by a bandage 
or by cotton with collodion. In most cases the latter will prove as 
effective as suturing of the two eyelids. Xerosis of the conjunctiva 
is also noticed, in very young infants, as the result of ill nutrition 
and consecutive marasmus. Most of the patients are from two to 
six months old. Proper and sufficient food will sometimes restore 
both the eye and the general health, but the mortality of these cases 
is very high. The same condition is found in children of from three 
to nine years (Thalberg, Forster). Several such cases were com- 
plicated with hemeralopia. 

Keratoconus — the conical raising of the centre of the cornea — 
requires a cautious thermo- or galvano-cauterization ; p annus, the 
centre of which is generally absolutely deprived of blood-vessels, 
demands stimulation. Daily insufflation of finely powdered calomel, 
continued for weeks or months, has met with some successes. Infec- 
tion with erysipelas and gonorrhoea has been observed to restore 
circulation and absorption, and the latter has been utilized, conse- 
quently, to accomplish these ends. An infusion of the seeds of 
jequirity (from three to five per cent.) has been used for the same 
purpose. Kobert prefers a one-per-cent. solution of its constituents, 
either abrin or ricin. 

Acute iritis is rare in infancy and childhood; its complication 
with glaucoma still more so. Of its two great causes, syphilis is 
almost exclusively of the hereditary variety, and rheumatism ex- 
hausts its main danger in starting endocarditis. 

Chronic iritis is not so often seen in early life, except in connec- 
tion with diffuse keratitis. The treatment of iritis is essentially iden- 
tical with that of the same affection in adults : hydrargyrum, iodides, 
and salicylates, according to the causal indication; instillations of 
atropine sulphate in distilled water ( 1 to 100 or 500) from two to ten 
times a day, or oftener if the danger of adhesion be imminent, with 
a two-per-cent. solution of cocaine muriate if the pain be great; 



532 



DISEASES OF THE EYE 



absolute rest in the acute variety ; dry heat ; a dark room ; iridotomy, 
or rather iridectomy, in most cases to loosen synechias and restore 
a pupil. Subconjunctival injections of corrosive sublimate (i to 
iooo, a few drops at a time) were used by Darier in 1892, and in 
Deutschmann's clinic. They are made near the margin of the cor- 
nea and downward, and are recommended principally for syphilitic 
affections of any part of the eye, except, perhaps, the optic nerve. 
Parenchymatous keratitis and iritis are also said to be amenable to 
the same treatment, though they be not syphilitic. Later reports are 
not quite so favorable. 

Suppurative cyclitis and a true abscess of the vitreous body are 
generally found together. Blindness is imminent, and enucleation 
to save the other eye becomes a necessity in almost every case, except 
in small children. In them the process has often exhausted itself, 
and may terminate in blindness and contraction without secondary 
irritation. When the abscess is small, part of it may be absorbed, 
and a white cloud in the lower part of the vitreous body, with feeble 
vision, may be the only evident results. 

Uncomplicated inflammation of the choroid is rare in children. 
Idiopathic choroido-retinitis is observed in later years in both eyes 
after it has lasted a long time. It certainly commences at an early 
age, but takes decades before it ends in contraction of the field of 
vision, degeneration of the retina and optic nerve, and turbidity of 
the vitreous body and the posterior capsule of the lens. In all cases, 
whether syphilitic or not, treatment with mercury and iodides is the 
only one either reliable or advisable. 

Congenital cataract demands an operation if vision be insufficient. 
If it be partial, atropine and iridectomy will suffice. Total cataract 
is rare in early years, but it may affect a number of persons in the 
same family; it may also, in exceptional cases, run a rapid course. 
More frequent is zonular cataract, which exhibits round its nucleus 
one or more turbid layers, followed by normal clear ones. As at 
the same time in a number of cases transverse phosphatic deposits 
are found in the teeth, zonular cataract has been attributed by many 
to rhachitis ; others connect it with convulsive diseases. Some con- 
stitutional disorder has been charged with being the cause, but no 
treatment has been advised, nor is there any apparent indication, 
except to correct the accompanying myopia. 

Diseases of the retina, the optic nerve, and the orbit show no par- 
ticular symptoms in the young, nor do they require special treat- 
ment different from that employed in advanced age. In many cases 
of acute or chronic leptomeningitis with ample effusion, blindness 



CATARACT. STRABISMUS. NYSTAGMUS 533 

depending on copious secretion in and around the tissue of the optic 
nerve is an early symptom. Early diagnosis of this condition, and 
treatment with mercury, iodides, and derivants (diuretics, purgatives, 
diaphoretics), may succeed in reducing the oedema and preventing 
compression and atrophy of the nerve. A number of such cases will 
get well. Lumbar puncture, performed once or repeatedly, ought to 
relieve pressure. Retinitis albuminurica occurs rarely on one eye 
only. Once it was found on the left side, when there was only one 
(the left) kidney. 

The tissues of the young eye being soft and elastic and expansible 
from internal pressure, glaucoma is rarely seen at an early age. Its 
place is taken by hydro phthalmos (buphthalmos) , which requires the 
operative procedures employed for the glaucoma of advanced age, 
— either iridectomy or sclerotomy. 

Strabismus is common in infants during the first few months of 
life. In them it is the result of an insufficient development of mus- 
cular power in general and of accommodation, and requires no treat- 
ment. That which makes its appearance during convalescence or in 
general hydrsemia terminates in recovery. Diphtheritic paralysis of 
the muscles of accommodation recovers spontaneously, or through 
generous feeding and the administration of iron and strychnine. Mus- 
cular paralyses resulting from cerebral diseases depend on these for 
their treatment, if any be possible. The ordinary form of ophthalmo- 
plegia, for instance, results from nuclear degeneration. Still, there 
are a number of hereditary cases reported by Gourzein and considered 
by him solely muscular. In them the ptosis was very marked ; there 
were also nystagmus and some amblyopia. Persistent strabismus in 
children of five or six years requires the same methods of operative 
treatment as that of adults. 

Nystagmus is a symptom only. It is either of central (sometimes 
rhachitical) origin, connected with an intracranial pseudoplasm (and 
choked disk), or hereditary atavy ; or dependent on locally diminished 
vision (affection of the cornea, lens, retina, or choroid) ; or on rotary 
spasm. It may be combined with strabismus, and may be horizontal, 
vertical, or diagonal; on one or both eyes. Bandaging one eye will 
sometimes stop it ; but the therapy is that of the underlying lesion. 



NAMES 



Abbe, 355 
Abel, 149 
Abercrombie, 483 
Adams, 368, 460 
Adler, 260 
Adriance, 7 
Ahlfeld, 88 
Albert, 512 
Aldrich, 149 
Alexandroff, 325 
Almquist, 481 
Aronson, 71 
Auerbach, 23 

B 
Baccelli, 371, 437 
Baginsky, 79, 194, 222, 

347, 419, 483 
Baldwin, 12 
Bamberger, 148 
Bani, 83 
Banti, 124, 150 
Barbiani, 47 
Barth, 276, 483 
Baruch, 57 
Bassett, 347 
Battersby, 281 
Baumgarten, 226 
Baumler, 205 
Bechterew, 306 
Beck, 395 
Becquerel, 6 
Beely, 281 

Behring, 71, 169, 247 
Beneke, 253 
Benney, 249 
Bernheim, 311 
Berti, 465 
Bethman, 223, 487 
Bezold, 520 
Biedert, 12, 15, 22, 29, 

330, 349, 423, 523, 530 



245, 247, 249, 



162, 276, 310, 



Bienwald, 103 

Bier, 500, 505 

Biermer, 355 

Bieser, 412 

Binz, 37, 265, 467 

Birch-Hirschfeld, 366 

Blauberg, 11 

Bloomer, 314 

Blumenbach, 152 

Boas, 31, 49 

Bohn, 395 

Bokay, 371, 419, 437 

Booker, 347 

Bouchard, 402 

Bouchut, 470 

Boulay, 408 

Bourneville, 273 

Boyer, 365 

Brackett, 494 

Braman, 483 

Braun, 303 

Brautigam, 382 

Brenz, 109 

Bretonneau, 32 

Broca, 356 

Brothers, 83 

Broussais, 1 

Brown, 249, 419 

Browne, 411 

Bruns, 105, 504 

Bryant, 447 

Buck, 16 

Budin, 100 

Buhl, 101 

Bulkley, 480 

Bull, 178 

Bunge, 6 

Biingner, 506 

C 

Caille, 24, 60, 74, 170, 230, 263, 374, 422 
Calot, 502 
Campbell, 379 

535 



536 



NAMES 



Cannon, 342 
Cantani, 153, 198 
Caron, 152 
Carstanjen, 115 
Cattani, 107 
Cazenave, 487 
Chapin, 88 
Charcot, 259, 307 
Charin, 368 
Chipault, 304 
Chossat, 1 
Chvostek, 299 
Coates, no 
Codivilla, 498 
Cohn, 17, 168 
Coit, 28, 30 

Coley, 71, 150, 310, 378 
Collin, 336 
Colmer, 291 
Comby, 126 
Concetti, 316 
Conquest, 281 
Couvelaire, 378 
Crede, 87, 96, 226, 462 
Cruveilhier, 371, 465 
Cunningham, 148 
Curling, 363 
Curschmann, 367 



Da Costa, 371 

Dana, 307 

D'Arcy Power, no, in, 405 

Darier, 532 

Debove, 163 

Delstauche, 324 

Demelin, 436 

Demme, 296, 307, 325, 395 

Demuth, 265 

De Renzi, 484 

Deutschmann, 532 

De Vigo, 180 

Dew, 83 

Dieffenbach, 395 

Dieulafoy, 323 

D'Outrepont, 88 

Dowd, 362 

Doyen, 146 

Dubler, 296 

Duclaux, 75 



Ducrey, 224 

Dujardin-Beaumetz, 49 
Duran, 374 
Diirck, 427 
Duval, 347 

E 
Ebstein, 17 
Edes, 148 
Edlefsen, 250 
Einhorn, 335 
Elder, 122 
Elliott, 101 
Elsaesser, 103, 129 
Eisner, 460 
Englisch, 395 
Eppinger, 466 
Epstein, 318, 483 
Erb, 147, 299. 
Ernstberger, 498. 
Escherich, 11, 18, 29, 107, 141, 249 
Esmarch, 365, 500, 505 
Eve, 498. 

Ewald, 31, 122, 335 
Ewing, 141, 246 



Faber, 122 

Falkland, 34 

Fede, 316 

Feldbausch, 74 

Feranini, 466 

Finkelstein, 152, 334 

Finsen, 486 

Fischer, 104, 325 

Flechsig, 306 

Fleisch, 300 

Flexner, 368, 468 

Fliigge, 19, 161 

Foa, 18 

Forchheimer, 458, 494 

Forster, 531 

Foster, 43 

Fountain, 233 

Fournier, 154, 178, 369 

Fowler, 362 

Fox, 222 

Fraenkel, 168, 318, 407. 444, 464 

Freeman, 24 

Freudenreich, 164 

Friedlander, 407 



NAMES 



537 



Friedleben, 147 
Friedreich, 291 
Friihwald, 311 
Fiirbringer, 276 

G 
Gaertner, 29, 126 
Ganghofner, 419 
Gerhardt, 16, 299, 302, 395 
Gerster, 203, 273, 325 
Ghillini, 513 
Gibier, 307 
Gilbert, 369 
Gillette, 494 
Glas, 300 
Gleitsmann, 171 
Goltz, 404 
Gorges, 455 
Gottstein, 324 
Gourc, 323 
Gourzein, 533 
Gowers, 145, 292, 306 
Graves, 1 
Greatgood, 281 
Grenser, 89 
Greves, 370 
Griesinger, 360 
Gruening, 318 
Guaita, 215 
Guerin, 394 
Guersant, 399 
Guillot, 94 
Guthrie, 379 
Guttmann, 240 
Guyon, 395 
Gwyn, 193 



H 



Haase, 281 
Haffkin, 71, 198 
Hagenbach, 264 
Hall, 83 
Hallet, no 
Hamill, 379 
Hammarsten, 3 
Harris, 412 
Harrison, 381 
Hawkins, 355 
Hayem, 103, 115 
Hebra, 480, 482 
Heffen, 459 
Heins, 18 



Heinze, 170 

Heitzmann, 125 

Hektoen, 368, 458 

Henoch, 152 

Heubner, 5, 22, 29, 127, 132, 152, 178, 

212, 245, 330, 419 
Hirschel, 300 
Hirschfeld, 35 
Hirschsprung, 334 
Hjort, 325 
Hodenpyl, 150 
Hodgkin, 123 
Hoffa, 269, 497, 498 
Hoffmann, 329 
Hofmeier, 97 
Hofmeister, 125 
Holt, 26, 87, 157, 180 
Honigmann, 17 
Hopkins, 416 
Horsley, 145 
Howard, 83 
Huber, 244, 323, 365 
Hueter, 224, 501 
Hufeland, 84 
Huguenin, 281 
Hun, 149, 273, 460 
Hunter, 282 
Hurd, 287 



Illing, 97 
Isenflamm, 152 
Isnard, 165 



J 



Jacoby, 279 
Jaeger, 195 
Japhe, 115 
Jastrowitz, 306 
Jenkins, 90 
Johannessen, 2, 291 
Johnston, 264 
Jolly, 306 
Jonnesco, 146 
Josseline, 365 

K 
Kamienski, 470 
Kaposi, 477 
Karewski, 325, 437 
Kassowitz, 37, 130, 235 
Keen, 273, 295 
Keller, 13 



538 



NAMES 



Kenned}', 264 

Kiliani, 279 

Kinnicutt, 121, 149, 336 

Klebs, 123, 168, 353 

Klemperer, 35 

Knaggs, 358 

Knapp, 303, 522 

Knochenstein, 17 

Knopfelmacher, 5 

Kober, 226 

Robert, 119, 531 

Koch, 152, 160, 168, 169, 505 

Kocher, 109, 305, 399, 500 

Koenig, 147, 447 

Kohts, 276, 409 

Koplik, 4, 142, 197, 318, 321, 502 

Kopp, 88 

Korowin, 22 

Korte, 109 

Koster, 504 

Kraske, 225 

Krause, 106, 504 

Kriiger, 30 

Kiilz, 152 

Kiimmell, 146, 356, 498 

Kussmaul, 48, 358 

Kiister, 504 

L 
Laborde, 84 
Ladd, 122 
Landau, 105, 336 
Landerer, 168, 505 
Landolt, 493 
Langenbeck, 497 
Langmann, 342, 478 
Lannelongue, 272, 486, 505 
Lanz, 132, 370 
Lassar, 92, 485 
Lauth, 84 
Lehmann, 4, 125 
Lenhartz, 279 
Lepine, 119 
Leroux, 152 
Le Tanneur, 168 
Letzerich, 265 
Levy, 105 
Lewin, 60, 69 
Lexer, 228 
Leyden, 425 
Liebig, 33 



Liebreich, 168 
Little, 276 
Loewenmeyer, 46 
Lorenz, 497, 498 
Lorey, 264 
Luschka, 322, 465 

M 

Macalister, 148 

Mace wen, 128, 511 

Macfarlane, 314 

Mackenzie, 148, 421 

Malay, 31 

Manson, 193 

Maragliano, 168 

Marchand, 125, 233 

Marfan, 5, 12 

Marie, 147, 148, 307 

Marmorek, 71, 216, 226, 462 

Marshall Hall, 83 

Matthiolin, 304 

McClymonds, 349 

Meckel, 98 

Meigs, 29 

Meltzer, 144, 193, 270, 343, 354 

Menard, 94 

Meyer, 225, 296, 322, 505, 511 

Michael, 264 

Mikulicz, 148, 494 

Milliken, 513 

Mills, 303 

Miquel, 164 

Mitchell, 122, 163, 503 

Moehli, 306 

Moleschott, 56 

Moncorvo, 264, 326, 474 

Monflier, 302 

Monti, 3, 115 

Moore, 88 

Morton, 270, 294 

Munk, 4 

Muskat, 498 

N 
Neiss, 125 
Neisser, 487 
Nelaton, 362 
Netter, 309 
Nettleship, 483 
Neuhaus, 488 
Neumann, 17, 97, 321, 407, 481 



NAMES 



539 



Neureutter, 405 
Nichols, 502 
Nicoladoni, 512 
Nicolaier, 106 
Nissin, 492 
Noeggerath, 371 
Nowack, 382 



O'Dwyer, 419 

Oertel, 46, 450, 451, 452, 459 

Oliver, 65 

Ombreville, 362 

Oppenheimer, 146 

Osier, 183 

Owen, 148 



Paci, 496 
Pacini, 83 
Packard, 425 
Paget, 147 
Palet, 379 
Palleske, 17 
Paltauf, 141 
Parrot, 499 
Pasteur, 291, 307 
Peck, 228 
Pernice, 84 
Pfaundler, 334 
Pfeiffer, 196 
Phelps, 509, 512 
Philippson, 484 
Pick, 367 
Piffard, 475 
Pitts, 358 
Pletzer, 371 
Pocas, 512 
Politzer, 521, 522 
Porak, 97 
Post, 512 
Potain, 441 
Prechtl, 12 
Prudden, 74 
Putnam, 87, 303 



Quimby, 423 
Quincke, 103, 



76, 345 



Rabinowitsch, 18, 162 

Radcliffe, 306 

Ramsay, 148 

Ranke, 6, 212, 419 

Rauchfuss, 505 

Raymond, 483 

Recklinghausen, 489 

Redman, 88 

Redon, 152 

Reed, 123 

Rehn, 265, 281, 378 

Reich, 82 

Reinbach, 146 

Renk, 19 

Ribbert, 353 

Ribemont, 82 

Riedel, 225 

Riehl, 481 

Rieth, 35 

Riga, 316 

Ritter, 481 

Roberts, 34 

Rohden, 164 

Rose, 367 

Rosenberg, 421 

Rosenheim, 31 

Rossbach, 265 

Rotch, 24, 60, 87, 122, 126 

Rothschild, 20 

Roux, 71 



Rudisch, 34, 153, 

449 
Rummo, 119 
Rumpf, 125 
Runge, 108 



185, 332, 335, 338, 



S 



Sachs, 273, 285, 303 

Sahli, 107, 167 

Salkowski, 4 

Sands, 358 

Sayre, 128, 444, 501, 512, 515 

Scanzoni, 94 

Scarpa, 168, 512 

Schaefer, 65 

Schallern, 108 

Scharlau, 106 

Schede, 496, 498 



540 



NAMES 



Schiff, 115 
Schiffer, 22 
Schild, 17 
Schillbach, 343 
Schleich, 72, 490 
Schleif, 147 
Schliep, 263 
Schlossmann, 4, 6, 8 
Schmidt, 125 
Schmieder, 378 
Schoenlein, 485 
Schott, 452, 459 
Schottmiiller, 193 
Schuchardt, 162 
Schuller, 83, 167 
Schultze, 83, 465 
Schwartze, 520, 522 
See, 457 
Seguin, 306 
Seibert, 24, 196, 212 
Semmola, 260 
Siedamgrotzky, 125 
Siegert, 419 
Siegfried, 4 
Silbermann, 526 
Silvester, 83, 245 
Smellie, 82 
Smith, 21, 48, 427 
Sokolow, 353 
Solden, 489 
Soldner, 5 
Solera, 31 
Solis Cohen, 148 
Soltmann, 270, 286 
Sondern, 379 
Sonnenberger, 265 
Sonnenburg, 356 
Sorgo, 146 
Soxhlet, 19, 60 
Spiegel, 387 
Spierig, 227 
Spiller, 295 
Springer, 28, 405 
Starr, 273 
Stockvis, 233 
Stoehr, 232 
Stokes, 449, 451 
Strelitz, 481 
Stromeyer, 512 
Symington, 321 



Tallerman, yy, 503 
Tarnier, 87 
Tay, 285 
Taylor, 509 
Thalberg, 531 
Thai Ion, 243 
Thiersch, 420 
Thin, 482 
Thompson, 304 
Thomsen, 271 
Thomson, 308, 334 
Tizzoni, 107 
Tordeus, 482 
Treves, 361 
Tripier, 125 
Troltsch, 522 
Trousseau, 86, 297, 440 
Trumpp, 419 
Tubby, 498 
Tyson, 354, 387 



U 



Uffelmann, 31 
Unna, 480, 489 



Vajda, 365 

Vander Veer, 273 

Vargas, 437, 502 

Vaughan, 349 

Vauquelin, 32 

Vernois, 6 

Villate, 505, 506 

Violet, 97 

Virchow, 108, 120, 125, 141 

Vogel, 132 

Voit, 35 

Volkmann, 496, 514 

W 

Waldeyer, 108 

Wang, 3 

Weaver, 368 

Weber, 20, 125, 306, 427, 484 

Wegeli, 152 

Wegner, 130, 178 

Wegscheider, 5 

Weichselbaum, 195 

Weill, 492 



NAMES 



541 



Weiss, 416 

Wendt, 265 

West, 196, 281, 459 

Widal, 183 

Widerhofer, 247, 419 

Widowitz, 482 

Wieland, 504 

Wilkinson, 477 

Willard Parker Hospital, 229 

Williams, 196, 449 

Winckel, 87, 101 

Winslow, 56 

Winternitz, 57 



Wittmaack, 4 
Witzel, 338 
Wladimiroff, 482 
Woihler, 83 
Wolf, 498, 513 
Wolff, 485 
Wright, 103, 404 
Wroblewski, 4, 28 



Zaufal, 522 
Ziemssen, 84 
Zweifel, 22, 30, 96 



INDEX 



Abscess in pneumonia, 434 

latero-pharyngeal, 320 

of liver, 370 

of vitreous body, 532 

perioesophageal, 325 

retro-pharyngeal, 320 

subdiaphragmatic, 370 
Acne, 475 

Acromegaly, 147, 149 
Actinomycosis of lung, 437 
Acute gastric catarrh, 39 

miliary tuberculosis, 158 

poliomyelitis, 291 

yellow atrophy, 370 
Addison's disease, 148, 149 
Adenitis, diphtheritic, 241 

sublingual, 314 
Adenoids, 322 

incontinence in, 322 
Adenoma, 108 

of parotid, 309 
Administration of medicines, 61 
locality of, 64 
mode of, 64 
Adrenalin, 149, 380 
Adrenals, 148 
Ailments, character of, 50 
Air, dry, 163 

in tuberculosis, 163 

moist, 163 
Albinismus, 524 
Albuminuria, cyclic, 383 

transient, 385 
Albumose, 33 
Alcohol, 35 

in diphtheria, 234 
Alexin, 71 
Alimentation, forcible, 49 

rectal, 47 
Alkalies, 38 



Alkaloids, 60 

Altitude in tuberculosis, 164 
Amaurotic family idiocy, 285 
Amygdalitis, 318 

follicular, 319 

phlegmonous, 319 
Amyotrophic sclerosis, 288 
Anaemia, 113 

arsenic in, 119 

causes of, 113 

chronic, 113 

climate in, 120 

cold water in, 120 

digitalis in, 117 

food in, 115 

iron in, 117 

montana, 121 

of the brain, 275 

oxygen in, 119 

ozone in, 119 

pernicious, 121 

splenic, 123, 150 

strychnine in, 117 
Anaesthesia by infiltration, 72 
Anchylostoma duodenale, 360 
Aneurism, 466 
Angioma, 468 

of mamma, 96 
Ankle-joint, 510 
Ankyloglossia, 317 
Antifebriles in typhoid, 187 
Antiperistalsis, 341 
Antipyresis by water, 57 
Antipyrin a styptic, 102 
Antitoxins, 71, 245, 418 
Anus, fissure of, 364 

prolapse of, 363 
Aphthae, Bednar's, 312 
Appendicitis, 353 
Arrest of development, 274 
Arsenic, 119, 298 

in tuberculosis, 165 



543 



544 



INDEX 



Arteries, atheromatous degeneration 
of, 467 

syphilis of, 467 

tuberculosis of, 467 
Arteritis, 99 
Arthritis deformans, 502 

in scrofula, 139 
Arthrodesis, 512 
Arthropathy, 259 
Articular rheumatism, 250 
Artificial nutriments, 35 
Ascaris, 359 
Ascites, 375 

chylosus, 376 
Asiatic cholera, 197 
Asphyxia, 81 

dangers of, 86 

electricity in, 84 

postnatal, 86 

prevention of, 81 
Aspiration of meconium, 82 

of tongue, 317 
Ass's milk, 6 
Asthma, 424 

dyspepticum, 425 
Ataxia, hereditary, 291 
Atelectasis, 86 
Atheroma, 488 

Atheromatous degeneration, 467 
Athetosis, 301 
Atresia of the iris, 524 

of the vagina, 402 
Atrophy, acute yellow, of the liver, 370 

muscular, 271 

of the skin, 489 
Autoinfection, 474 



Bacilli, 158 

inhalation of, 161 
invasion of, 158 
protected by fat, 18 

Bacillus butyricus, 18 
typhosus, 183 

Bacteria, intestinal, 340 

Balanitis, 401 

Balano-posthitis, 401 

Banti's disease, 124 

Barley, 15 

Barley-water, 24 



Barlow's disease, 153 
Basedow's disease, 145 
Bathing, 57 

of the newly-born, 92 
temperature of, 92 
Bednar's aphthae, 312 
Beef, scraped, 34 
Beef-broth, 33 
Beef-tea, 33 
Berberin, 123 
Bicarbonate in milk, 26 
Bier's treatment, 507 
Bifid tongue, 316 

Biliary duct, obstruction of the, 370 
Bilirubin, 103 
Bladder, 389 

calculus in the, 394 

reflex contraction of the, 393 

spasm of the, 390 

tumors of the, 394 
Blennorrhcea, 107 
Blepharitis, 526 
Blood, diseases of the, 113 
Blood-nodules, 465 
Blood-vessels, 466 

dilatation of the, 468 

hypoplastic, 466 

thin, 467 
Bone-marrow, 122 
Bones, 495, 498 

congenital enlargement of the, 495 

curvatures of the, 495 

fractures of the, 498 

in scrofula, 139 

malformations of the, 495 

supernumerary fingers and toes, 

495 

Bovine tuberculosis, 162 
Brachial plexus, 270 
Brain abscess, 274 

anaemia of the, 275 

arrest of development of the, 274 

embolisms in the, 275 

hypersemia of the, 275 

in typhoid, 190 

inflammation of the, 274 

syphilis of the, 274 

thrombosis in the, 275 

tumors, 273 
Breast-milk, germs in, 17 



INDEX 



545 



Bromides, 296 
Bronchi, 422 
Bronchial catarrh, 422 

chronic, 423 
Bronchiectasis, 424 
Bronchitis, 422 

fibrinous, J2» 424 
Bulbar paralysis, 283 
Buphthalmos, 533 
Burns, 471 

of the eye, 526 



Cachexia strumipriva, 143 
Calcium in the body. 44 

in the food, 44 

phosphate, 44 
Calculi, renal, 387 
Calculus of the bladder, 394 
Cane-sugar, 12, 24 
Cantharidal collodion, 78 
Cantharides, contraindication to, 78 

effect of, on the kidneys, JJ 
Caput obstipum, 493 
Carbolic acid, 75 
Carbon oxide poisoning, 80 
depletion in, 80 
Carcinoma of the lung, 437 

of the stomach, 339 
Cardiac tonics, 51 

in anaemia, 117 
Carditis in rheumatism, 250, 255 
Casein of woman's and cow's milk, 3, 
Caseous pneumonia, 158 
Catalepsy, 300 
Cataract, congenital, 532 
Catarrh, intestinal, 41 

of rectum, 362 
Catarrhal fever, 197 
Centrifuging, effect of, 18 

of milk, 26 
Cereals, 15 

Cerebral anaemia, 275 
diseases, diet in, 46 
meningitis, 274 
Cerebro-spinal meningitis, 194 
Chalazion, 524 
Chemosis, 528 
Chicken-pox, 222 



Chloroform, 74 

action of, on adipose children, 75 
of, on chronic pulmonary dis- 
eases, 74 
of, on the heart, 74 
of, on the newly-born, 74 
sudden death from, 73 
Chlorosis, 120 

altitude in, 121 
Cholera, Asiatic, 197 

infantum, causes of, 17 
Chorea in rheumatism, 251, 255 
major, 300 
minor, 296 
Choroid, 532 

Chronic ankylosing inflammation, 503 
articular rheumatism, 502 
gastric catarrh, 39 
hydrocephalus, 280 
pulmonary tuberculosis, 158 
Chyluria, 470 

Circulation, organs of, 449 
Cirrhosis of the liver, 368 

pigmentary, 369 
Climate, 120 

in tuberculosis, 163 
Club-foot, 293, 511 
Coal-tar preparations, 57 
Cod-liver oil, 8, 127, 137 
Cold, 197 

as an antipyretic, 429 
water in anaemia, 120 
Colds, 165 
Colic, 344 
Colles's law, 175 
Colloidal silver, 216 
Coloboma, 524 
Colon, absorption in the, 47 

dilatation of the, 112 
Communication of tuberculosis, 161 
Complications of scarlatina, 215 
Compressed air in tuberculosis, 170 
Concretions in the efferent ducts, 310 
Congenital atrophy of the skin, 488 
constipation, in 
diseases of the skin, 487 
enlargement of the toes, 495 
fistulas of the neck, 324 
lipoma, 488 
luxations, 496 



35 



546 



INDEX 



Congenital myotonia, 271 

sarcoma, 488 

spastic muscular contraction, 276 
Conjunctiva, 526 
Conjunctivitis, 139, 526 

chemosis of, 528 

chronic, 526 

diphtheritic, 528 

follicular, 529 

gonorrhceal, 528 

granular, 529 
Constipation, 14, 42, 339 

apparent, 339 

causes and treatment of, 42 

congenital, in 

in rhachitis, 134 

in typhoid, 188 

mechanical obstruction a cause of, 
340 
Constitution, diseases of the, 113 
Consumptive mother, 162 
Contractures, 290 
Convalescence from typhoid, 192 
Convulsions, 295 
Cord, cutting of the, 81 

treatment of the, 96 
Cough, periodic, 425 

reflex, 425 
Couveuse, 87 
Coxitis, 509 
Craniectomy, 272 
Craniotabes, 129 
Craniotomy, 272 
Cream mixture, 29 
Crede's ointment, 101, 216 
Creosote, 167 

in tuberculosis, 167 
Cretinism, 143, 285 
Croup, 415 

pseudo-membranous, 416 
Cryptorchis, 404 
Curare, 62, 106 
Cyanosis, 464 

neurotic, 482 
Cyclic albuminuria, 383 
Cyclitis, 532 
Cyclopia, 524 
Cystic degeneration of the kidney, 378 

hygroma, 324 

tumors of the peritoneum, 376 



Cysticercus in the eye, 524 
Cystitis, 389 

Cysts of the hymen, 406 
umbilical, 108 



Dactylitis, 500 
Deaf-mutism, 523 
Deformity of the chest-wall, 437 
Degeneration, acute fatty, 101, 104 
Dementia, 284 
Dental ulceration, 316 
Dentition, difficult, 315 
Depletion, 79 

local, 79 
Dermatitis, 475 

exfoliativa, 481 
Dermoid cysts, 489 
Development, 52 
Deviation of the septum, 408 
Diabetes insipidus, 156 

mellitus, 154 
Diarrhoea, 344 

fat, 7, 8 

from milk-sugar, 11 

in typhoid, 188 

summer, 351 
Diathesis, hemorrhagic, 151 
Diet in lymphatism, 141 
Difficult dentition, 315 
Digestive organs, 309 
Digitalis, 117, 121, 454 

in tuberculosis, 166 
Dilatation of the colon, 112 

of the heart, 459 

of the stomach, 333 
Dilution of milk, 23 
Diphtheria, 207, 226 

alcohol in, 234 

antitoxin, 245 

heart-failure in, 23s 

immunization in, 250 

lymph-nodes in, 231, 241 

mercury in, 243 

mucous membranes in, 232 

nephritis in, 244 

nose in, 237 

paralysis in, 244 

pneumonia in, 244 

prevention of, 228 



INDEX 



547 



Diphtheria, pseudo-membranes in, 239 

tonsils in, 231 

treatment of, 236, 242 
Disinfectants, 210 
Disinfection, methods of, 209 
Disseminated sclerosis, 283 
Drugs in tuberculosis, 165 
Dry air, 163 
Ductless glands, 142 
Ductus arteriosus Botalli, 465 

venosus Arantii, 103, 105 
Duodenal hemorrhages, 336 

ulceration, 336 
Duodenum, ulceration of the, 40 
Dysentery, 198 
Dyspepsia, 37, 326, 330 

causes of, 37 

nervous, 335 

treatment of, 38 
Dystrophy, 271 
Dysuria, 390 

E 
Ear, 516 

foreign bodies in the, 516 

furuncles in the, 519 

malformations of the, 516 

polypus in the, 518 
Echinococcus of the kidney, 379 

of the liver, 371 

of the lung, 437 
Eclampsia, 295 
Ecthyma, 478 
Eczema, 78, 139, 478 

papular, 478 

seborrhceicum, 480 
Egg, 34 

Elbow- joint, 510 
Electricity, 293, 343 

in nervous diseases, 269 
Elephantiasis, 470 
Embolism in the brain, 275 
Emphysema, 435 

subcutaneous, 448, 472 
Empyema, 442 
Encephalocele, 283 
Enchondroma in the oral cavity, 309 

of the larynx, 421 
Endocarditis, 460 

in rheumatism, 250, 255 
Enema, evacuant, 67 



Enema, how to give an, 48 

medicated, 66 
Enteritis, acute, 41 

chronic, 41 

follicular, 349 

membranous, 341 

mucous, 341 
Ephemeral fever, 44, 197 
Epicanthus, 524 

Epidemic cerebro-spinal meningitis, 194 
Epididymis, carcinoma of the, 405 

dermoids of the, 405 

sarcoma of the, 405 

tuberculosis of the, 405 
Epilepsy, 301 

Jacksonian, 302, 303 
Epileptic dementia, 285 
Epinephrin, 149 
Epistaxis, 413 
Epithelial pearls, 310 
Epithelioma of the larynx, 421 
Epulis, 309 
Erysipelas, 99, 223 

of the pharynx, 319 
Erythema, 78, 472 

exudativum multiplex, 474 

in rheumatism, 259 

nodosum, 259, 474 

papulosum, 259 
Erythromelalgia, 483 
Essential anaemia, 121 
Ether, 75 

action of, on respiratory diseases, 
74 
of, on the kidneys, 74 
Eustachian tube, 519 
Excursions, 56 
Exomphalos, 109 
Exophthalmic goitre, 145 
Exophthalmos, recurrent, 482 
Exostoses, multiple, 495 
Expectant treatment, 51 
Exsection of the rib, 447 
Extracts of organs, 72 
Eye, 524 

chalazion, 524 

cysticercus of the, 524 

dermoid cysts of the, 524 

foreign bodies in the, 525 

glioma of the, 525 



548 



INDEX 



Eye, gumma of the, 525 
injuries of the, 525 
lipoma of the, 524 
malformations of the, 524 
neoplasms of the, 524 
of the newly-born, 107 
tubercles of the, 525 

Eyelids, 526 



Facial nerve, paralysis of the, 270 
Farinacea, 32 

in diarrhceal diseases, 42 
Fat acids, 7 

diarrhoea, 7, 8, 344 

different in woman's and cow' 
milk, 6 

in faeces, 7 

in milk, 5 

oleic acid in, 91 

protects bacilli, 18 
Fatty degeneration, acute, 101, 104 

infiltration of the liver, 368 
Favus, 485 
Febris bullosa, 482 
Feeding, forcible, 49 

general rules for, 1, 2 

nasal, 49 

principles of, 14 
Femoral hernia, 362 
Fever, 44 

catarrhal, 197 

diet in, 44 

glandular, 196 

in rheumatism, 251 

intermittent, 180 

relapsing, 194 

typhoid, 45, 183 
Fibrinous bronchitis, 73 
Fibroma in the oral cavity, 309 

of the larynx, 421 
Filariasis, 376 
Filtration of milk, 24 
Fingers, supernumerary, 495 

synechia of the, 495 
Fissura sterni congenita, 437 
Fissure of the anus, 364 

of the palate, 309 
Fissures of the tongue, 317 
Fistula in ano, 172 



Fistulas, congenital, 324 
Flat-foot, 513 
Floating kidney, 379 

liver, 367 
Foetus, diseases of the, 285 
Follicular enteritis, 349 
Fomentations, warm, 79 
Food, artificial, 3 

of the newly-born, 15 
Forcible feeding, 49 
Foreign bodies in the ear, 516 
in the larynx, 422 
in the oesophagus, 325 
Fractures, 498 

Fraenum of the upper lip, 309 
Franklinism, 270 
Frost-bites, 472 
Functional murmurs, 4^0 
Fungus, umbilical, 108 
Funnel chest, 437 
Furunculosis, 477 



Gangrene of the lung, 437 

symmetrical cutaneous, 483 

umbilical, 99 
Gargles, 76 
Gastric catarrh, 117 
acute, 331 
chronic, 332 

hemorrhage, 336 

ulcerations, 40, 336 
Gastritis, 39, 331 
Gastromalacia, 336 
Gelatin, 15, 103, 173 
Genital organs, 377 
Genu valgum, 510 

varum, 511 
Geographical tongue, 317 
Germs in breast-milk, 17 

in meconium, 17 
Giant growth, 495 
Gingivitis, 318 
Gland, ductless, 142 

pituitary, 147 
Glandular fever, 196 
Glans penis, imperforation of the, 

395 

Glaucoma, 533 
Glioma, 525 



INDEX 



549 



Glossitis, 317 

Glottis, paralysis of the, 420 

spasm of the, 420 
Goat's milk, 15 
Goitre, 142 

exophthalmic, 145 
Gonitis, 510 

Gonorrhoeal rheumatism, 257 
Granuloma, 108 
Graves's disease, 145 
Green-stick fractures, 128 
Growing pain, 251 
Growth, 53 
Guaiacol, 167 

in tuberculosis, 167 
Gum arabic, 15 
Gumma of the eye, 525 



H 

Hsematoma of the mitral valve, 465 

of the sterno-cleido-mastoid, 90 
Hsematuria, 379 
Haemoglobinuria, 379 

epidemic, 101, 104 
Haemophilia, 151, 467 
Harelip, 309 
Hay bacillus, 18 
Heart, congenital diseases of the, 464 

dilatation of the, 459 

diseases, 55, 449 
exercise in, 451 

in lymphatism, 141 

in scarlatina, 214 

in tuberculosis, 166 

in typhoid, 189 

neuroses of the, 464 

ptosis of the, 465 

tonics, doses of, 63 

undersize of the, 466 
Helminthes, 358 

cause anaemia, 121 
Hemicrania, 271 

Hemiplegia, infantile spastic, 283 
Hemorrhage from the pharynx, 320, 
322 

gastric and duodenal, 336 

of the vagina, 403 

pulmonary, 172, 436 

symmetrical cutaneous, 483 



Hemorrhage, umbilical, . 102 
Hemorrhages in scarlatina, 214 

in typhoid, 189 
Hemorrhagic diathesis, 151 
Hepatoptosis, 367 
Hereditary ataxia, 291 

syphilis, 46, 174 
Hernia, femoral, 362 

inguinal, no, 361 

of the brain, 283 

of the lung, 437 

strangulated, no 

umbilical, 109, 361 
Herpes, 197, 484 

tonsurans, 485 

zoster, 484 
High temperatures, 57 

in scarlatina, 212 
Hip -joint, 509 
Hodgkin's disease, 123 
Horseshoe kidney, 378 
Hot-air apparatus, yj 
Huntingdon's chorea, 299 
Hydrencephaloid, 10, 41 
Hydrocele, 405 

of the spermatic cord, 406 
Hydrocephalus, 280, 286 
Hydrochloric acid, 15, 31 
Hydronephrosis, 379 
Hydropericardium, 464 
Hydrophthalmos, 533 
Hydrops articulorum intermittens, 

482 
Hydrorrhachis, 293 
Hydrotherapy, 57 
Hydrothorax, 448 
Hygienic directions, 55 
Hygroma, 470, 489 

of the tongue, 317 
Hymen, cyst of the, 406 

imperforate, 403 
Hyperemia of the brain, 275 
Hypertrophic osteo-arthropathy, 148 
Hypertrophy of the heart, 387 

of the pylorus, 33s 
Hypophysis, 147 

treatment with, 147, 148 
Hypospadias, 395 
Hysteria, 300 
Hysterical fever, 301 



55o 



INDEX 



I 

Ice-water, 79 

Ichthyol in tuberculosis, 168 
Ichthyosis, 488 
Icterus, 103 
Idiocy, 272, 285 
Immaturity, 87 
Immunization, 250 
Imperforate hymen, 403 
Impetigo, 478 

contagiosa, 485 
Improper food, 326 
Inanition, 2, 53 
Incompatibles, 62 
Incontinence of urine, 390 
Indicanuria, 474 

Infantile spastic hemiplegia, 283 
Infarction of uric acid, 377 
Infectious diseases, 157 
Inflammation, chronic ankylosing, 
Influenza, 260 
Inguinal hernia, 361 
Inhalation, 72. 

of ammonium muriate, 73 

of amyl nitrite. 73 

of bacilli, 161 

of chloroform, 73 

of steam, 73 

of turpentine, 73 
Injections, subcutaneous, 68 

of mercury, 69 
Insanity, moral, 284 
Insufficient innervation, 117 
Insufflation, 82 
Intermittent fever, 180 
arsenic in, 182 
ergot in, 182 
eucalyptus in, 182 
iron in, 182 
quinine in, 181 
types of, 180 
Internal secretion, 65, 142 
Intertrigo, 475 
Intestinal autoinfection, 474 

catarrh, 346 

disorders, 339 

obstruction, 340 
Intestines, tuberculosis of the, 171 
Intrathoracic lymph-bodies, 438 
Intubation, 419 



503 



Intussusception, 357 
Invagination, 357 
Iodine, 137 
Iodoform, 75 
Iodothyrin, 144 
Iritis, 531 
Iron, 113, 117, 137 
Irritable bladder, 390 



Jaundice, 26 

endemic, 371 

epidemic, 371 
Joints, 495, 503 

in scarlatina, 214 

inflammation of the, 503 



Keloid, 488 
Kephalhsematoma, 89 

internal, 89 
Keratitis, 139, 529 

diffuse, 530 

neuroparalytic, 531 

parenchymatous, 530 
Keratoconus, 531 
Keratomalacia, 531 
Kidneys, 377 

cystic degeneration of the, 378 

horseshoe, 378 

lipoma of the, 378 

malformations of the, 378 

pseudoplasms of the, 378 

sarcoma of the, 378 

tuberculosis of the, 378 

unicity of the, 378 
Knee-joint, 510 
Knock-knee, 510 
Kyphosis, 515 

L 
Lab ferment, 4 
Laborde's method, 84 
Lachrymal stenosis, 526 
Lancing gums, 315 
Landry's paralysis, 288 
Laryngismus, 140 

stridulus, 132 
Laryngitis, 415 

diphtheritic, 416 



INDEX 



551 



Larynx, 415 

acute catarrh of the, 415 

chronic catarrh of the, 416 

congenital stricture of the, 422 

croup of the, 415 

foreign body in the, 422 

neoplasms of the, 421 

neurosis of the, 420 

stenosis of the, 419 

tuberculosis of the, 170 
Lateral sclerosis, 288 
Latero-pharyngeal abscess, 320 
Leeches, 80 

place of application of, 80 
Leontiasis, 488 
Leptothrix, 314, 318 
Leucocythsemia, 122 
Leukaemia, 122 
Lichen, 475, 476 

acuminatus, 476 

planus, 476 

scrofulosorum, 476 
Light, 56 

Lime-water, 26, 40 
Lipoma of the kidney, 378 

of the tongue, 316 
Lipomatosis, 141, 149 
Little's disease, 276 
Liver, 366 

acute atrophy of the, 370 

adenoma of the, 353 

cancer of the, 371 

cirrhosis of the, 368 

congestion of the, 369 

echinococcus of the, 371 

enlargement of the, 366 

fatty infiltration of the, 368 

floating, 367 

inflammation of the, 370 

suppuration of the, 370 
Local treatment of diphtheria, 236 
Lumbar puncture, 194, 274, 278, 282 
Lungs, 426 

emphysema of the, 435 

gangrene of the, 437 

hemorrhage from the, 436 

infarction of the, 436 

oedema of the, 436 

pseudoplasms of the, 437 
Lupus, 486 



Lupus erythematosus, 486 
Luxation, congenital, 496 

of the hip-joint, 496 
of the knee-joint, 498 
of the radius, 498 
of the scapula, 498 
of the shoulder, 498 
Lymphangioma, 470 
cystic, 470 

of the peritoneum, 376 
of the tongue, 317 
Lymphatic state, 140 
Lymphatism, diet in, 141 

sudden death from, 140, 141 
Lymph-bodies in rhachitis, 133 
intrathoracic, 438 
mesenteric, 352 
treatment of, in scrofula, 138 
Lymph-ducts, 10 
Lymph-nodes in diphtheria, 231 
Lymph-vessels, 470 



M 

Macroglossia, 317 

Malaria, 180 

Malformations of the ear, 516 

of the eye, 524 
Malt, 15, 137 
Mamma, 94 
Mania, 284 
Massage, 269 
Mastitis, 94 
Mastoid process, 522 
Masturbation, 394, 403 
Measles, 207, 217 

convulsions in, 217 

hemorrhage in, 218 
Meat-soups, 32 
Meconium, aspiration of, 82 

germs in, 17 
Medicine, preventive, 60 
Medicines, administration of, 61 

doses of, 63 

effects of, 62 

large doses of, 63 

protracted administration of, 64 

tolerance of, 63 
Melsena, 104, 336 
Membranous enteritis, 341 



552 



INDEX 



Meningitis, 54, 274 

cerebral, 274 

cerebro-spinal, 279 

serous, 279 

tubercular, 276 
Meningocele, 283 

spuria, 284 
Mental diseases, 284 
Mercury, 63 

in diphtheria, 243 

in laryngitis, 410 
Merycism, 335 

Mesenteric lymph-bodies, 352 
Meteorismus in typhoid, 187 
Methods of disinfection, 209 
Microcephalus, 272 
Microphthalmia, 524 
Milia, 310 

Miliary tuberculosis, 158 
Milk, boiled, 16 

changed by sterilization, 21 

dilution of, 23 

effect of boiling, 16 

fat in, 5 

filtration of, 24 

in diarrhceal diseases, 42 

in gastric ulcer, 41 

modification of, 25 

various conditions of, 3 
Milk-sugar, 10 

changes in, 10 

different in milks, 10 

milk acidulated by, 11 
Mineral springs, 120, 138 
Mitral valve, hsematoma of the, 465 
Moist air, 163 

Molluscum contagiosum, 486 
Monomania, 285 
Moral insanity, 284 
Mountain anaemia, 121 
Mouth, 309 

cleaning of the, 81 
Mouth-breathing, 319, 323 
Mucous enteritis, 341 
Muguet, 313 
Multiple sclerosis, 288 
Mumps, 220 

Murmurs, functional, 450 
Muscles, 491 

in syphilis, 491 



Muscles in tuberculosis, 491 

of accommodation, 533 

trophoneurosis of the, 492 
Muscular atrophy, 271, 493 

dystrophy, 493 

ischsemia, 492 

paralysis, 492 

pseudo-hypertrophy, 271 

rheumatism, 260, 494 
Mustard-bath, 77 
Myasthenia, 493 
Myelitis, transverse, 288 
Myelocele, 294 
Myocarditis, 458 
Myositis, 491 

chronic, 492 

hemorrhagic, 491 

infectious, 491 

ossifying, 492 

petrifying, 492 

rheumatic, 491 

traumatic, 491 
Myotonia, congenital, 271, 493 
Myringitis, 517, 519 
Myxcedema, 143, 144 

N 

Nsevus, 468 

lipomatodes, 489 

pigmentosus, 489 

verrucosus, 489 
Nares, 407 

abscess of the, 410 

acute catarrh of the, 407 

chronic catarrh of the, 409 

congenital obstruction of the, 407 

foreign body in the, 412 

hemorrhage from the, 413 

polypus of the, 412 

scrofula of the, 410 

syphilis of the, 410 

tuberculosis of the, 410 

ulceration of the, 414 
Nasal tissue, hypertrophy of the, 409 
Neck, neoplasms of the, 489 

of the bladder, irritability of the, 

393 
muscular debility of the, 392 
Neoplasms of the epididymis, 405 
of the eye, 524 



INDEX 



553 



Neoplasms of the heart, 466 

of the larynx, 421 

of the neck, 489 

of the ovary, 406 

of the skin, 487 
Nephrectomy, 389 
Nephritis, 23, 381 

acute, 383 

chronic, 385 

in diphtheria, 244 

in scarlatina, 215 

subacute, 384 
Nephropexy, 379 
Nephrotomy, 389 
Nerves, 294 
Nervous dyspepsia, 335 

system, 268 

operations on the, 272 
Neuritis, 294 
Neuro-fibroma, 295 
Neuroma, 295 
Neuromyositis, 491, 492 
Neuropathic oedema, 482 
Neuropathies of the skin, 481 
Neurosis of the heart, 464 

of the larynx, 420 
Neurotic cyanosis, 482 
Newly-born, treatment of the, 81, 93 
Night-sweats, 173 

terrors, 287 
Nodulated rheumatism, 258 
Noma, 314 

of the vulva, 400 
Non-tubercular phthisis, 435 
Nose, diphtheria of the, 237 
Nucleon, 4 

Nutriments, artificial, 35 
Nystagmus, 533 



Oatmeal-water, 24 

Obstruction of the intestines, 340 

of the urethra, 395 
(Edema, angio-neurotic, 482 

neuropathic, 482 

pulmonary, 436 
(Esophagus, 325 

foreign bodies in the, 325 

stricture of the, 325 
Oidium, 313 



Ointments into the nostrils, 76 

Oleic acid in fat, 91 

Omphalitis, 99 

Omphalocele, 109 

Operations, blood-pressure in, 75 

duration of, 75 

in tuberculosis, 170 
Optic nerve, 532 
Oral cavity, 309 

enchondroma, 309 

fibroma, 309 

osteoma, 309 

sarcoma, 309 

tumors, 309 
Orbit, 532 
Orchitis, 404 
Organ extracts, 72 
Organotherapy, 65, 149 
Osteitis, 499 

tubercular, 499 
Osteo-arthropathy, 148 
Osteochondritis, 499 
Osteoclasy, 128 

Osteoma in the oral cavity, 309 
Osteomyelitis, 499 
Osteotonry, 128 
Otitis, 139 

externa, 516 

media, 519 
Ovary, neoplasm of the, 406 
Oxygen, 74 

Oxyuris vermicularis, 360 
Ozone, 74 

in tuberculosis, 74, 170 

in whooping-cough, 74 



Palate, diphtheritic, 311 
fissure of the, 309 
perforation of the, 311 
syphilitic, 311 

Pancreatic juice, 23, 27, 30 

Pannus, 531 

Papilloma of the larynx, 421 

Paralysis, bulbar, 283 
diphtheritic, 244 
ischsemic muscular, 492 
Landry's, 288 
of the brachial plexus, 270 
of the facial nerve, 270 



554 



INDEX 



Paralysis of the glottis, 420 

spastic spinal,. 288 
Paranuclein, 4 
Paraphimosis, 400 
Parasyphilis, 179 
Paratyphlitis, 356 
Paratyphoid, 193 
Paresis, 279, 285 
Parotid, adenoma of the, 309 
Parotids, 30 
Parotitis, 220, 315 
Passive hypersemia, 275 
Pasteurization, 19 

at home, 19 

daily, 20 
Pavor nocturnus, 287 
Pearls, epithelial, 310 
Peliosis rheumatica, 151, 258 
Pemphigus, 480 

exfoliitivus, 481 

in scarlatina, 215 

in syphilis, 177 

neuroticus chronicus, 482 
Pentosuria, 154 

Peptic glands, atrophy of the, 121 
Peptones, 33, 34 
Periangeitis, 157 
Pericardial obliteration, 367 
Pericarditis, 463 

Pericardium, syphilis of the, 464 
Perichondritis, 499 
Perihepatitis, 367 
Perimastitis, 94 
Periodic night-cough, 425 
Pericesophageal abscess, 325 
Periostitis, 499 

albuminous, 499 
Peripheric paralysis, 295 
Periproctitis, 362 
Perisplenitis, 150 
Peristalsis, excessive, 341, 349 

incomplete, 341 
Peritoneum, cystic tumors of the, 376 

lymphangioma of the, 376 
Peritonitis, 372 

chronic, 374 

in typhoid, 189 

local, 373 

tubercular, 374 
Pernicious anaemia, 121 



Pertussis, 261 
Pes calcaneus, 512 

equinus, 512 

valgus, 513 

varus, 511 
Pharyngitis, 318 

catarrhal, 318 

erysipelatous, 319 
Pharynx, hemorrhage from the, 320 

in tuberculosis, 171 
Phimosis, 397 
Phlebitis, 99 
Phosphaturia, 392 
Phosphorus, 27, 130, 138, 166 

in rhachitis, 130 
Phthisis, non-tubercular, 435 
Physical therapeutics, 60 
Physiology, 52 
Pigeon-breast, 127 

Pigmentary cirrhosis of the liver, 369 
Piperin, 123 
Pituitary gland, 147 
Pleura, 438 

hemorrhages of the, 448 
Pleuritis, 55, 438 

in scarlatina, 214 

operation in, 440 

puncture in, 441 
Pneumonia, 55, 426 

abscess in, 434 

acute lobular, 427 

caseous, 158 

catarrhal, 432 

digitalis in, 431 

etiology of, 426 

heart in, 430 

hypostatic, 435 

in diphtheria, 244 

in scarlatina, 214 

interstitial, 427, 435 

malaria in, 434 
Pneumothorax, 448 
Polioencephalitis, 276 
Poliomyelitis, 288, 291 
Polyneuritis, 271, 294 
Polypus of the nose, 412 

of the rectum, 365 

complication of, with adenoids, 

365 
of the urethra, 406 



INDEX 



555 



Posture in bed, 54 
Potassium iodide, 63 

ointments of, 64 
Powders absorb moisture, 62 

how to give, 61 
Predisposition, anatomical and phys- 
iological, 52 
Premature infants, 113 
Prematurity, 87 
Prepuce, 395 

adhesion of the, 396 

diphtheria of the, 400 

epithelial pearls of the, 396 

infections of the, 399 

synechia of the, 397 
Preventive measures against conta- 
gious diseases, 207 

medicine, 60 
Primary splenomegaly, 150 
Proctitis, 362 
Profeta's law, 175 

Progressive juvenile muscular dystro- 
phy, 271 
Prolapse of rectum, 363 
Prurigo, 475, 476 
Pseudo-diphtheria, 227 

bacilli of, 227 
Pseudo-hypertrophy, 271, 493 
Pseudo-leukaemia, 123 
Pseudo-membranes, 239 
Pseudo-membranous croup, 416 
antitoxin in, 418 
mercurials in, 417 
Pseudo-paralysis, 492 
Pseudoplasms of the lung, 437 

of the spleen, 149 

of the thyroid, 142 
Psoriasis, 146 

thyroid in, 146, 149, 487 
Psychical diseases, 284 
Puberty, 53 

Puerperal sepsis, 100, 101 
Pulmonary hemorrhage, 55, 172 
Puncture, lumbar, 194, 274, 278, 282 
Purpura, 151 
Pyelitis, 385, 388 
Pyelonephritis, 388 
Pylorus, congenital stenosis of, 333 
Pyopneumothorax, 448 
Pyothorax, 444 



Quinine, preparations of, 
taste of, 61 



Ranula, 310 

Rectal alimentation, 47 

Rectum, 66 

absorption in the, 47 

anatomy of the, 66 

catarrh of the, 362 

injections into the, 66 

polypus of the, 365 

prolapse of the, 363 
Recurrent exophthalmos, 482 
Relapsing fever, 194 
Renal calculi, 23, 387 

catarrh, 388 

diseases, diet in, 46 
Respiratory diseases, diet in, 46 

organs, 407 

in rhachitis, 133 
Retina, 532 

Retinitis albuminurica, 533 
Retropharyngeal abscess, 55, 320 
Rhachitis, 32, 124 

air in, 124 

bones in, 128 

constipation in, 134 

cranial bones in, 129 

definition of, 125 

diet in, 43 

digestive disorders in, 126 

green-stick fractures in, 128 

hygiene in, 125 

iron in, 132 

lactic acid in, 125 

lymph-bodies in, 133 

muscular weakness in, 134 

phosphorus in, 130 

respiratory organs in, 133 

sodium chloride in, 131 

thyroid in, 132 
Rheumatism, 250 

acute articular, 253 

chorea in, 251 

chronic articular, 259, 502 

diagnosis of, 251 

diet in acute, 47 

endocarditis in, 250, 255 



556 



INDEX 



Rheumatism, erythema in, 259 

fever in, 251 

gonorrhoea^ 257 

in scarlatina, 213 

joints in, 254 

muscular, 260, 494 

nodosus, 258 

peliosis, 258 

temperature in, 256 

Rheumatoid gout, 502 

Rhinitis, 407 

Riga's disease, 316 

Rotatory spasm, 308 

Rotheln, 219 

Rubella, 219 

Rumination, 335 

Rupia, 478 

S 

Sacrum, anatomy of the, 48 
St. Vitus's dance, 296 
Salaam spasm, 307 
Saline solution, 10 
Saliva, 22, 27, 30, 32 
Salt, 13 

in constipation, 14 
Sanguineous cysts, 489 
Sarcoma in oral cavity, 309 

of the kidney, 378 

of the lung, 437 

of the spleen, 70 

of the stomach, 339 

of the tongue, 309 

of the tonsil, 309 

of the vagina, 406 
Scabies, 484 
Scarlatina, 204 

after wounds, 206 

complications in, 215 

heart in, 214 

hemorrhages in, 214 

joints in, 214 

pleuritis in, 214 

pneumonia in, 214 

prevention of, 207 

pseudo-membranes in, 212 

rheumatism in, 213 
School inspection, 206 
Schooling, 55 
Schultze's method, 83 
Sclerema, 91 



Scleroderma, 483 
Scoliosis, 513 

prevention of, 129 
Scrofula, 135 

difference of, from tuberculosis, 
135 

effect of digestive disorders in, 136 
Scrofuloderma, 487 
Scurvy, 24, 151 

infantile, 153 
Seborrhcea, 475 
Secretion, internal, 65 
Sepsis, 45 

Sequelae of typhoid, 193 
Serotherapy, 65, 71 
Serums in tuberculosis, 168 
Sigmoid flexure, 48, in 

diverticula of, 112 
Silvester's method, 83 
Sinapisms, yy 
Skimmed milk, 15 
Skin, 76 

atheroma of the, 488 

atrophy of the, 489 

congenital diseases of the, 487 

cysts, dermoid, 488 

fibroma of the, 488 

ichthyosis of the, 488 

in heart disease, 452 

in scrofula, 140 

keloid of the, 488 

lipoma of the, 487 

neoplasms of the, 487 

neuropathies of the, 481 

papilloma of the, 481 

sarcoma of the, 488 

tuberculosis of the, 487 
Sodium bicarbonate, 38 
in milk, 26 

chloride, 13, 328 
effect of, 14 
in artificial food, 14 
Soluble silver, 216 
Somatose, 35 
Soxhlet, 25 
Spasm, hissing, 308 

nutans, 307 

of the glottis, 420 

rotatory, 308 

salaam, 307 



INDEX 



557 



Spasm, saltatory, 308 

snapping, 308 

sneezing, 308 

spitting, 308 

yawning, 308 
Spastic hemiplegia, 276 

spinal paralysis, 288 
Spermatic cord, hydrocele of the, 406 
Sphincter, stenosis of the, 390 
Spina bifida, 293 

ventosa, 499 
Spinal hemorrhage, 288 

leptomeningitis, 288 

meningitis, 288 

pachymeningitis, 288 
Spine, 288 

arrests of development of the, 288 

inflammations of the, 288 
Spleen, 149 

abscess of the, 150 

embolism of the, 150 

enlargement of the, 150 

in rhachitis, 150 

in syphilis, 150 

infarctions of the, 150 

pseudoplasms of the, 149 

removal of the, 124 

rupture of the, 150 

sarcoma of the, 70 
Splenic anaemia, 123, 150 
Splenomegaly, primary, 150 
Spondylitis, 54, 507 
Spray, 72 

Spurious meningocele, 284 
Stammering, 308 
Starch dextrinized in the rectum, 48 

digestion of, 329 
Stenosis, lachrymal, 526 

of the larynx, 419 

of the pylorus, 333 

of the trachea, 419 
Sterilization, 18 

changes by, 20 
Sterno-cleido-mastoid, haematoma of 

the, 90 
Stomacace, 311 
Stomach, 326 

acute atrophy of the, 331 

carcinoma of the, 339 

chronic catarrh of the, 332 



Stomach diet, importance of, 326 
dilatation of the, 333 
inflammation of the, 331 
sarcoma of the, 339 
ulceration of the, 40, 336 
Stomatitis, 311 
aphthous, 312 
catarrhal, 311 
follicular, 311 
hemorrhagic, 312 
membranous, 313 
mercurial, 312 
ulcerous, 311 
Stone in the bladder, 394 
Strabismus, 533 
Stricture of the larynx, 422 
of the oesophagus, 325 
Strychnine, 117 

Subcutaneous emphysema, 448, 472 
injections, 68 

of alkaloids, 69 
of apomorphine, 69 
of arsenic, 70 
of caffeine, 70 
of morphine, 69 
of pilocarpine, 69 
of quinine, 70 
of stimulants, 69 
of strychnine, 70 
Sublingual adenitis, 314 
Submaxillary gland, 30 
Substitutes for breast-milk, 15 
Sudden death, 141 

after chloroform, 73 
Sugar, 10 

absorption of, 13 
causes diarrhoea, 13 
Suicide, 284 
Summer diarrhoea, 351 
Supernumerary fingers, 495 
Suppositories, 68 
Suprarenal melasma, 148 
Surgical tuberculosis, 505 
Swallowing of the tongue, 317 
Sweetbread, 34 
Symmetrical cutaneous gangrene, 48? 

hemorrhage, 483 
Synechia of the fingers, 495 
Syphilis, 174 

hereditary, 174 



558 



INDEX 



Syphilis, hereditary, arteritis in, 178 
diet in, 46, 175 
iodides in, 178 
mercury in, 176 
pemphigus in, 177 
ribs in, 178 
of the pericardium, 464 
of the testes, 405 
Syrups, 61 



Tabes, 288, 290 
Taenia mediocanellata, 359 
Taka-diastase, 31 
Tarsal joint, 510 
Telangiectasia, 468 
Temperature, high, 57 
influence of, 17 
rise easily, 58 

meaning of, 58 
Testis, syphilis of, 405 
Tetanin, 107 
Tetanus, 106 
Tetany, 299 
Therapeutics, physical, 60 

preventive, 136 
Thoracocentesis, 444 
Throat, 318 
Thrombosis, 467 

in the brain, 275 
Thrush, 313 
Thymus, 133, 146, 148 
in rhachitis, 132 

sudden death from an enlarged, 147 
Thyro-antitoxin, 145 
Thyroglossal duct, 319 
Thyroid gland, 142 

atrophy of the, with myxe- 
dema, 142 

carcinoma of the, 142 

dermoid in the, 142 

in rhachitis, 132 

inflammation of the, 142 

syphilis of the, 142 

tuberculosis of the, 142 
Thyroidin, 144 
Toes, congenital enlargement of the, 

495 
Tongue, 2, 316 

adhesion of the, 317 



Tongue ankyloglossia, 317 

aspiration of the, 317 

bifid, 316 

congenital anomalies of the, 316 

cystic hygroma of the, 317 

dermoids of the, 316 

fissures of the, 317 

geographical, 317 

in tuberculosis, 171 

lipoma of the, 316 

lymphangioma of the, 317 

macroglossia, 317 

sarcoma of the, 309, 316 

ulceration of the, 318 
Tonsil, sarcoma of the, 310 
Tonsillitis, 318 
Tonsils, 318 

in diphtheria, 231 

parenchymatous inflammation of 
the, 319 
chronic, 319 
Torticollis, 493 
Trachea, stenosis of the, 419 
Trachoma, 528 
Transient albuminuria, 385 
Transmission of tuberculosis, 161 
Transverse myelitis, 288 
Treatment, expectant, 51 

preventive, 53 
Trismus, 106 
Trusses, no 

Tubercle bacilli in milk, butter, cheese, 
and meat, 162 

of iris, 525 
Tubercular lymph-bodies, 353 

meningitis, 276 

peritonitis, 374 
Tuberculin, 162, 168 
Tuberculocidin, 168 
Tuberculosis, 157 

air in, 163 

altitude in, 164 

arsenic in, 165 

bovine, 162 

causes of, 159 

climate in, 163 

communication of, 161 

compressed air in, 170 

creosote in, 167 

digitalis in, 166 



INDEX 



559 



Tuberculosis, drugs in, 165 

guaiacol in, 167 

heredity of, 160 

ichthyol in, 168 

in diabetes, 155 

lymph-bodies in, 157 

miliary, 158 

of the anus, 172 

of the blood-vessels, 157 

of the epididymis, 405 

of the intestines, 171 

of the kidney, 378 

of the larynx, 170 

of the pharynx, 171 

of the skin, 487 

of the tongue, 171 

operations in, 170 

ozone in, 170 

preventive treatment of, 159 

serums in, 168 

skin in, 165 

surgical, 505 

transmission of, 161 

turpentine in, 170 
Tumors in the brain, 273 
Turpentine in tuberculosis, 170 
Tympanites in typhoid, 187 
Typhoid fever, 45, 183 
aborted, 184 
antifebriles in, 187 
brain in, 185 
bronchitis in, 185 
complications of, 193 
consecutive diseases of, 193 
constipation in, 188 
convalescence from, 192 
diarrhoea in, 188 
diet in, 45 
feeding in, 185 
heart in, 189 
hemorrhages in, 189 
high temperatures in, 186 
hydrochloric acid in, 45 
peritonitis in, 189 
preventive treatment of, 184 
stimulants in, 45 
treatment of, 185 
tympanites in, 187 
Typho-malaria, 193 
Typhus, 194 



U 



Ulceration, gastric and duodenal, 336 

of the nares, 414 
Umbilical cysts, 109 

fungus, 108 

gangrene, 99 

hemorrhage, 102 

hernia, 109, 361 
Undersize of the heart, 466 
Unicity of the kidney, 378 
Uraemia, 80 

depletion in, 80 
Ureter, catarrh of the, 388 
Urethra, congenital stricture of the, 
395 

epithelial obstruction of the, 395 

membranous obstruction of the, 

395 

polypus of the, 406 
Uric acid infarction, 23, 377 
Uricaemia, 392 
Urine, incontinence of, 390, 391 

retention of, 390, 391 
Urticaria, 482 

pigmentosa, 483 



Vaccinia, 222 

Vagina, atresia of the, 402 

catarrh of the, 401 

hemorrhage from the, 403 

noma of the, 400 

sarcoma of the, 406 
Varicella, 222 
Variola, 221 
Variolois, 221 
Veal-broth, 33 

Veins, thrombosis of the, 467 
Venesection, 79 
Verrucae, 482 

Vertebral tuberculosis, 507 
Vesicatory, 77 
Vitiligo, 482 

Vitreous body, abscess of the, 532 
Vomiting, 38 

in scarlatina, 213 
Vulva, catarrh of the, 401 

noma of the, 400 
Vulvitis, aphthous, 400 



560 



Warts, 482 
Water, 57 

boiled, 9 

cold, 58 

effects of, 58 

hot, 59 

in diseases, 9 

in food, 326 

warm, 59 



INDEX 



W 



Webbed fingers, 495 
Weil's disease, 194 
Werlhof's disease, 151 
Whooping-cough, 261 



X 



Xanthopsia, 360 
Xeroderma, 488 
Xerosis, 531 



THE END. 





Hil 




